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Case Study by: Jason Blalack

** This is a work in progress and currently only intended for review by the CHA (Chinese Herb Academy) and The Traditional Chinese Medicine Yahoo Groups :

Working Introduction:

Below is a case record from my clinical practice in Boulder, Colorado that highlights the strength of Chinese medicine’s treatment for common colds and flu. It also illustrates a problem with the health-care system in the U.S. and hopefully will spark a deeper much needed dialogue between Western and Chinese medicine.

Case record (2011): [Patient] X, a male in his mid-30s, came in with a chief complaint of fevers of unknown origin that had persisted for six weeks. The fevers were severe in the afternoons and would also wake him around 3-4 am, when his Advil “wore-off”.

He recently was hospitalized for eight days, when his fevers started reaching 104°F. They were characterized by a strong sensation of shivering cold (rigors). After multiple courses of antibiotics, a loss of 25 lbs. (he was not overweight), and $72,000 in hospital bills, he was discharged. Although his fevers had finally decreased he had no diagnosis, and within days of being discharged his fevers started to return. After a couple days of worsening symptoms he came in to see me for a Chinese medicine consult.

History: Prior to the fevers he was overworked and was not sleeping much. For the last few years he had been taking Metformin for diabetes and Pepcid for acid reflux.

Six weeks prior, he went to urgent care complaining of elevated temperature (102°) and chills, severe headache at the temples and occiput that was worse lying down, sore throat, and a “sinus infection”  with nasal congestion. He was given Augmentin, which caused him to vomit. After four days of vomiting and feeling generally worse he was told to stop the Augmentin and given a second antibiotic, Azithromycin. Two days later his condition worsened and his fevers climbed to 104°F. He ended up in the emergency room where he had elevated liver enzymes (possibly from the Augmentin), normal CBC (including WBC), and was suspected to have left lobe pneumonia. He was given IV antibiotics and fluids and remained in the hospital for 8 days while they ran a battery of tests. Nothing conclusive was found.

In my office: The patient reported severe fatigue (unable to work), fever and chills, no sensation of heaviness, no thirst, no dryness of the lips or mouth, and the stools had recently become drier. Previous to the last few days he generally felt cold with the fevers, but now he had started to feel hot with the fevers. He was taking eight Advil a day to control the fevers (4 every 12 hours). When the Advil would wear off the fever would spike and he would start to sweat. His pulse was slippery, floating, and rapid. His tongue had cracks, no coat, was slightly red with small purple spots on the underside of the tongue.

Diagnosis & pathodynamic: Wind-cold pathogen constrained in the muscle layer transforming to heat in the protective level.

Treatment Principles: Use acrid cool medicinals to clear and resolve (disperse and vent out heat in the exterior).

Formula: Two packets of Honeysuckle and Forsythia Powder (yin qiao san) were given (bulk herbs). Cook time was 15 minutes. One packet was consumed over two days, taken between meals three times a day.

Prescription:

  • jing jie (Schizonepetae Herba)6g (add)
  • jin yin hua (Lonicerae Flos)15g
  • lian qiao (Forsythiae Fructus)15g
  • dan zhu ye (Lophatheri Herba)6g
  • niu bang zi (Arctii Fructus9g
  • jie geng (Platycodi Radix)6g
  • bo he (Menthae haplocalycis Herba)3g (add)
  • dan dou chi (Sojae Semen preparatum)12g (add)
  • lu gen (Phragmitis Rhizoma recens)18g
  • gan cao (Glycyrrhizae Radix)3g

Result: After one packet the patient was back at work and although his muscles were achy, they felt stronger. After finishing two packets, he requested a two-bag refill from the pharmacy. He worked five continuous full days and at the next appointment (one week later) he was having no fevers, taking no Advil, and felt almost 100%. At this point I gave him a constitutional formula based on ban xia xie xin tang (Pinellia Decoction to Drain the Epigastrium). He had no recurrence of the fevers.

Commentary:

Although this case had a fortunate outcome with a straightforward treatment, I think it highlights some important issues in regard to Chinese medicine theory as well as Western and Chinese medicine’s roles in treating disease.

Chinese medicine commentary

This case started with a fairly typical flu, most likely caused by a wind-cold pathogen. The prescribed antibiotics constrained the pathogen in the muscle layer. Antibiotics, usually considered cold and bitter, are not appropriate in such situations, which require an acrid warm approach to disperse and release the exterior cold.

The patient had a fairly robust constitution, which helped prevent the pathogen from sinking into the interior. Over time though, the pathogen transformed to heat. The fluids were only starting to become affected as evidenced by the dry stools, yet the lips and mouth were not dry. This was not a pathogen that had entered the Large Intestine or yang ming. The presentation was fairly straightforward from a Chinese medicine diagnostic perspective. We had a lingering pathogen in the superficial aspects of the body and a clear heat and resolving the exterior method was appropriate.

Some points to keep in mind:

  1. High fever can still be an exterior problem
  2. An ongoing fever for 6 weeks to 6 months can still be an exterior problem
  3. The lack of dryness and internal organ symptoms gives evidence that the pathogen was still on the exterior.

It should be noted that the treatment, although fairly basic, was not a mechanical, reflexive action. In my practice I rarely give an unmodified formula, let alone Honeysuckle and Forsythia Powder (yin qiao san). I was a little embarrassed when writing this case up, having published material discussing how this specific formula (and formulas in general) are best thought of as ideas and should not be given as presented in our textbooks. Although formulas are best constructed for each individual presentation, in this case, the stock formula seemed to be spot on.

Furthermore I do not want to suggest that Honeysuckle and Forsythia Powder (yin qiao san) should be given indiscriminately in other cases of fever of unknown origin. One still should perform an appropriate differential diagnosis.

I think though that the nature of the condition, being an uncomplicated pattern, and the simplicity of the treatment really speaks to the strength of the Chinese medicine model compared to Western medicine’s approach to diagnosis and treatment.

The integration of Western and Chinese medicine

Although this is only a single case it does represent a common clinical occurrence and is also emblematic of a greater problem in health care. Cold and flu are treated very successfully with Chinese medicine, even ones that seem fairly urgent. Chinese medicine has quite an arsenal of options that have actively been developed over 2000+ years of clinical practice. There is case study after case study in Chinese and English that demonstrate the effectiveness of the Chinese medicine approach for these conditions.

Western medicine has little to offer since most colds and flu are viral. However, antibiotics are often given because the patient requests  “something” or there is a suspected (usually secondary) bacterial infection. Although antibiotics can have their place, the majority of the time Chinese medicine can resolve the problem without their use, hence avoiding the multiple issues that come along with antibiotic treatment.

All health care providers are trying to come up with the best care possible for our patients. Hence it would be worthwhile if we could respect each other’s  strengths while acknowledging our own weaknesses. Chinese medicine doctors all too often write off Western medicine because it is not “natural,”  or supposedly just treats the “symptoms.”  Western medicine writes off  “alternative”  medicine due to lack of rigorous research.

Is it unreasonable for practitioners to refer to other modalities that have a better handle on a given illness? Ultimately we should all be working together, creating a team that centers on the patient’s best interest.

I often have patients ask me to converse with their Western doctors about collaborative treatments. Some MDs that are open-minded enough to engage in such discussions. Quite simply though, most medical doctors make little effort to understand Chinese medicine. Hence one is unable to discuss Chinese medicine on its own terms (its theory and terminology) and is forced to artificially describe its actions and methods in pseudo-Western medicine lingo.

In contrast, Chinese medicine physicians not only are required to take Western medical courses in their curriculum, ranging from Western physical exam to pharmacology and pathophysiology, but often actively seek out ways to integrate the knowledge into Chinese medicine.

Chinese medicine in 2006 treated more than 3.1 million U.S. adults with acupuncture[1]. Major insurance companies, such as Kaiser, not only cover Chinese medicinal services but are starting to discuss Chinese medicine on its own terms.[2] Is it not reasonable for Western doctors to have at least one course in their training centered on Chinese medicine? Is it not reasonable for them to strive for at least a basic understanding of a medicine that has been around for over 3000+ years?

In conclusion, Chinese medicine is more appropriate than Western medicine for many conditions. However discovering what these may be is a bit difficult if the two cannot openly work together. Quite simply, Chinese medicine must first be understood on its own terms (within its own system). For example, WebMD states,

“Research in China and worldwide has shown Chinese medicine to be helpful for many types of illness. Because Chinese medicine differs from Western medical practice in diagnosis and treatment methods, it is difficult to apply Western scientific standards to it.”

That is, Chinese medicine most often gives individualized treatments based on constitution and whole-body presentation, not a Western disease or a mere symptom. Hence typical research models do not accurately reflect Chinese medicine’s abilities.

However, we can learn from case studies and individual doctor’s experience and see how Chinese medicine thinks about disease as well as what can be successfully treated. What will it take for Western medicine to acknowledge Chinese medicine and start to work together?

Please feel free to post any comments.


[1] http://nccam.nih.gov/health/whatiscam/chinesemed.htm

[2] https://members.kaiserpermanente.org/kpweb/healthency.do?hwid=aa140227spec

[3] http://www.webmd.com/balance/tc/chinese-medicine-topic-overview

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Showing 12 comments
  • Matt Haug LAc
    Reply

    1.Dx: “wind cold pathogen..in muscle layer, turn to heat in protctive layer” you might want to add a sentence or two explaining what this means.

    2.same with TP:”outthrust heat in exterior” what does this mean? add explanation. what is the exterior in CM? and what does it entail?

    3.under Some Point to Keep in Mind: “3. the lack of dryness (where?) in the mouth and on the lips and the fact that the bowel movements were not affected tells us that the pathogen (what is a pathogen? explain) was still exterior.

    4.Cut this sentence: (unnecessary)”This is certainly a territory that puts pt in middle..”

    5. rewrite: Is it unreasonable a Western Medcine practitoner to refer a patient to a Doctor of Chinese Medince (cut modality, vague)…

    6. rewrite: “Do MDs really need a double blind study to know that Chinese
    Med is effective?”
    7. In addition what if Chinese Medicine prationers started reffering more to thier Western Medince counterparts?
    8. cut: “jiont treatments” instead: collaborative treatments.

    9. cut: “There is certainty” just “Some MDs are open to discussoin..”

    10. cut “Quite simply though” just: Most MDs…
    11. rewrite: “So one is unable to discuss CM on its own terms.”Period. question: what are its terms? what is its language and what does it say?

    12. {I dont know if we want MDs flocking to our schools, the way they are now}perhaps we could go to them.

    Hope this helps,,Matt Haug LAc

  • Thomas Avery Garran
    Reply

    Nice job Jason, I like it. I think it needs some polishing, but overall excellent. I’ll try to find time to come back to it tomorrow and give you some feedback.
    Thomas

  • Phil Rogers
    Reply

    Very fine work, Jason.

    However, the Quackbusters’ case would be as follows:

    1. Flu / viral infections usually run their course in time.

    2. Yours was a single uncontrolled case.

    3. The Chinese Formula had no effect on the outcome because it was given just before self-cure was about to happen!

    You and I know better, but that is what those biased against CHM will say.

    Keep up the good work.
    Phil

  • Sharon Weizenbaum
    Reply

    Hi Jason, Great case! A question I thought of as I read this is about your diagnosis of constraint “in the muscle layer”. What led you to this idea. I only saw the symptom of achy muscles in the result section. If he did have achy muscles at the initial visit, couldn’t that be from constraint at the protective level? Also what is the muscle layer? How did this diagnosis influence your treatment? It seems that the treatment only addressed the protective layer heat.

    Thanks

    Sharon

    • Jason Blalack
      Reply

      Hi Sharon,

      Thanks for taking the time to read this case. The diagnosis of wind-cold in the muscle layer is retroactive, since I was unable to perform an intake it represents a diagnosis over time, which relates to the pathogenesis of the condition when I saw him.

      I did not initially use the term “protective level” because I reserve this term for warm disease conditions. Thus, I used this term when the pathogen transformed into a more heat presentation. In the very beginning stages the pathogen was (most likely) in the exterior and one could use the term protective yang, which is commonly used to describe the location of a (wind) cold pathogen.

      However, after the antibiotics the fever spiked and the symptoms worsened. One might ask, why did the symptoms increase in severity? Initially though, there was no indication that the pathogen had transformed to heat. Therefore the logical conclusion is that pathogen was pushed inward and was constrained.
      The muscle layer is said to be slightly below exterior of the body. There are superficial and deeper layers of the muscle layer.

      The term “muscle layer” is used in a few patterns in CM and there are handful of medicinals that are said to address the muscle layer. For example, ma huang, gui zhi, shi gao, ge gen, chai hu, bo he, sang ye, mu zei, sheng ma etc.

      Gui zhi tang is a common formula that releases pathogenic influences from the muscle layer. Its symptoms are “Fever and chills unrelieved by sweating, headache, aversion to wind, stiff neck, nasal congestion, dry heaves, and no particular thirst”

      There are other formulas associated with the muscle layer such as, Bupleurum and Kudzu Decoction to Release the Muscle Layer (chai ge jie ji tang), which is considered a fundamental formula for venting lurking pathogens from the muscle layer, where it discusses Bupleuri Radix (chai hu) as “an essential herb for releasing the muscle layer because it has the ability to vent heat from below the immediate surface of the exterior.”

      Hence, before warm disease theory this was a primary location for lurking pathogens and was also a common location for pathogens to become constrained, especially when turning heat.

      But in the end, this is all a story because I was unable to see the patient at that point in time. Hence, I could only treat what I saw, and did. But sometimes making sense of the etiology is helpful. For example, knowing that a pathogen can constrain in the muscle layer and cause severe symptoms helps me have the confidence that the pathogen did not enter the interior, and understand what the Antibiotics may have done. Therefore, it is not a symptom per se, of for example muscle aches, that leads one to believe that the pathogen is constrained in the muscle layer it’s more about the progression of disease. Hope that helps…

  • Sharon Weizenbaum
    Reply

    Thanks Jason for your thoughtful reply. I think you are saying that you would use this term when the pathogen – in this case a wind cold pathogen – goes a bit deeper and yet is not in the Qi level nor in the Yang Ming or Shao Yang…It is stuck just a bit deeper than the surface layer…In this case it was the lingering nature of this fever that took you to that terminology? How did this effect what you than did?

    I appreciate your careful use of diagnostic terminology to locate the place that needs help and to determine just what type of help is needed.

    best,

    Sharon

  • Jason Blalack
    Reply

    Sharon,

    If it was not clear, when I treated the patient the pathogen was no longer in the “muscle layer”. The wind-cold in the muscle layer is part of the pathodynamic (etiology). Thus it explains the past to help us better understand the present.

    If I saw the patient three weeks earlier (and my assumptions were correct) I would’ve treated a wind-cold pathogen in the muscle layer. However, by the time I saw the patient the pathogen had already transformed to heat and I used a more warm disease strategy.

    Hence, by understanding that a pathogen can get lodged in the muscle layer and cause this sort of problem indirectly informed my diagnosis and treatment because one can understand that this type of pattern can occur without entering into the interior. That is, it gave me the confidence (by understanding the possibilities) to still treat the protective level, which many say is a slightly deeper layer that surface patterns.

    Could one get to this point without understanding the etiology? and remember, it is only a story…

    Make sense?

  • Cedrick Horsfield
    Reply

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  • Delmar Dutchess
    Reply

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  • Jamie
    Reply

    This is such an interesting case study. I think that in the West, Chinese Medicine is still regarded as something for “prevention” or for the management of pain disorders and stress-related symptoms. Our work as practitioners is to inform the general public of their options when dealing with acute illnesses, such as cold and flu viruses.

  • alex
    Reply

    Hi Jason, thank you very much for the detailed analysis and explanation. Keep up the good work.
    One thing i dont understand. From the looks of it, your grasp of TCM is more than sufficient to heal many diseases and in fact, to ‘reverse’ damages caused by conventional western medicine. If so, why are you still propogating the joint collaborative effort of TCM-Western approach? It sounded counter-intuitive to me. Also, by this time, you would have noticed the polar opposite of how TCM approaches a disease versus Western approach. For example, cough syrup, anti-inflammatory, steroids, panadols etc generally works to suppress and ‘push’ symptoms/pathogen deeper whilst the correct TCM approach is actually to release to exterior. Just think of measles/chicken pox/rashes, how does western approach this? By reducing the rashes and the sooner it goes away the better a doctor/medicine is rated. Yet, from TCM perspective, we know this is the worse type of solution for long term….

  • Jason Blalack
    Reply

    Before I comment on this, can I ask what you are referring to of, “still propogating the joint collaborative effort of TCM-Western approach” – Jason

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