The Error of Our Ways

What Mismanaged Cases Teach Us About the Practice of Chinese Medicine.
by Charles Chace

In 1991 I published an anthology of medical case histories by senior practitioners of TCM in China.  This anthology was a reflection of my long-standing interest in the case history literature of Chinese medicine and it  contained an essay by the well known modern physician Qin Bo-wei on the importance of case histories in clinical practice. In this essay Qin Bo-wei asserted that reports of mismanaged or failed cases were at least as edifying as chronicles of cases handled with consummate virtuosity. This perspective greatly broadened my understanding of the application of the case history literature. At the time this anthology went to press, however, I had seen little in the way of botched cases in the literature and I contented myself with including those writings, however successful, that added something to the existing English literature.

In the meantime I have been slowly collecting more and more chronicles of mismanaged cases. They frequently appear in the Chinese language TCM journals where they have become nearly prevalent enough to constitute a sub-genre of the medical literature. Mismanaged cases will often appear in the context of articles dealing with signs and symptoms that do not necessarily mean what we usually attribute them to, for instance, rapid pulses which reflect cold conditions.  Aside from the reassuring novelty of an ostensibly skilled physician actually admitting in writing that he or she did not get it right the first time, I have found these cases much more informative than the cut and dried miracle cures that are the topic of most written case reports. There are a number of reasons for this.

One factor that I believe mismanaged cases so instructive is the natural tendency on the part of the physician to present each step of the therapeutic process in a manner that seems reasonable and logical so as to justify his or her decision making process. The initial evaluation and diagnosis, and treatment, although ultimately shown to be erroneous, is most often presented in a manner that leaves us as readers nodding our heads in affirmation at every step of the report. The diagnosis makes sense based on the information gathered from the evaluation. The treatment principles and therapy are also a logical extension of the diagnosis. Of course, since we are reading about a case which has been mismanaged, we know that these initial evaluations are erroneous. The reporter then presents the insight that leads him or her on a different tack, outlining this new approach with equally compelling logic. This type of reporting more accurately reflects the thought processes we as practitioners undergo in treating our own difficult cases.

While commentaries on successful case reports may be lengthy, they more often tend to be terse little statements summing up a key bit of theory from the Inner Classic (Nei Jing) or the Treatise on Damage by Cold (Shang Han Lun) that was so adroitly pressed into play in that particular case. The reader is often left feeling that the case and the path to its happy resolution is all so self evident that any child could have managed it. In commenting on a mismanaged case, however, the author is compelled to explain his or her reasoning at every stage of the game in fairly precise detail. Discussions pertaining to mishandled cases tends to be much more expository in nature.

Another factor that makes mismanaged cases so edifying is that the error a physician makes in treating a patient and the subsequent correction of that error often has relevance far beyond the scope of the illness being treated. This is not to be nearly as evident in smoothly handled cases. For instance, what have we learned when we read a case history on the treatment of unilateral headache that was cured with one acupuncture treatment? We have learned that a particular patient, presenting with a particular pattern was treated with consummate success with a particular point combination on a specific day. If we ourselves have just such a patient, presenting with an identical pattern and headache, and who’s condition has resisted treatment then this case report may be a godsend. If, on the other hand, this is not the case, then we simply have a point formulary for a given pattern of unilateral headache that we ought to try some time. There may be some key diagnostic or therapeutic principle implicit in such a case report but it is often overshadowed by the overall facility with which the physician has handled the case. When we read a report of a mismanaged case, the implications of the error made by the physician often go far beyond the case at hand. Although the complaint may be hypertension, as in one of the cases below, we have learned something more about the nature of geriatric medicine general, or about delineating between root and branch issues. We then step back into the clinic not only with a pithy tidbit on treating hypertension but with a slightly more evolved sense of how to practice Chinese medicine as a whole. We are more acutely aware that things are not necessarily as they seem and are hopefully less likely to fall into the same traps as the reporting physician.

What follows are four case histories and their attendant discussions that  are illustrative of the value of documenting our botched cases as well as our shining victories. While we may all misread a pulse or fail to see some subtle hue in a tongue,  I believe that many of the clinical errors we make occur after all the information is in and we are engaged in processing it. Our errors most often reflect our failure to perceive the entire clinical picture. The following cases are examples of this principle. The successful resolution of these cases was not a result of the accumulation of some new piece of information, rather it relied upon a more accurate interpretation of the existing data. The first two cases are translations of case reports which were published specifically to demonstrate how an error was rectified. The second set of cases originally appeared in the context of a discussion of Zhang Zhong-jing’s interpretation of rapid pulses and so the tenor of the discussion is somewhat different.

Since there is no standard format for case reporting and the examples below come from rather disparate sources, I have rearranged the information in them to provide a more homogenous presentation. The medical terminology used in this article is based on Wiseman’s Glossary of Chinese Medical Terms and Acupuncture Points  

Balancing the Liver, and Extinguishing Wind and actually Aggravating Wind
A 65 year old female was first examined on March 7th 1988. She complained of hypertensive cephalic clouding, and impaired vision in both eyes for many years. She had taken Bluish Dogbane-Apocynum Venetum compound (Luo Bu Ma) and Salvia Tablets (Dan Shen Pian) on many occasions. One week previously, after being exposed to a draft, she experienced cephalic clouding, distension and pain, and cough with vomiting of phlegm. With the administration of Western medication her blood pressure normalized and the cough also diminished. The cephalic clouding, distension and pain did not diminish, however, and her limbs felt weak and lacked strength. She experienced heavy-headedness, her legs felt light such that she was unable to stand up, and her intake of food was diminished. The patient therefore sought treatment through Chinese herbal medicine.

When she was examined her pulse was floating, wiry, and slippery. The tip and sides of her tongue were red, while the coat was slightly slimy and yellow.

The pattern was discriminated as that of an external contraction of wind heat precipitating an ascending hyperactivity of liver yang, which, in turn produced the dizziness. Two formula, Mori and Chrysanthemum Drink (Sang Ju Yin) and Settling the Liver Extinguishing Wind Decoction (Zhen Gan Xi Feng Tang) with modifications were prescribed. This contained:

Haematitum (Dai Zhu Shi) 30g.
Concha Ostrea  (Mu Li) 30g.
Os Draconis (Long Gu) 30g.
Plastrum Testudinis  (Gui Ban) 15g.
Carapax Amydae  (Bie Jia) 15g.
Radix Paeoniae Lactiflorae (Bai Shao) 15g.
Radix Scrophulariae Ningponensis (Xuan Shen) 15g.
Radix Scutellariae Baicalensis ( Huang Qin) 15g.
Rhizoma Corydalis Yanhusuo (Xuan Hu) 12g.
Fructus Meliae Toosendan (Chuan Lian) 12g.
Herba Mentha Haplocalycis (Bo He) 15g.
Folium Mori Albae (Sang Ye) 15g.
Flos Chrysanthemi Morifolii  (Ju Hua) 15g.
Radix Platycodi Grandiflori (Jie Geng) 10g.
Semen Pruni Armeniacae (Xing Ren ) 10g.  
Radix Achyranthes Bidentatae (Niu Xi) 10g.
Radix Glycyrrhizae Uralensis (Gan Cao) 6g.
The patient was next examined on March 10th.

The cephalic clouding had not diminished, the sliminess on her tongue coat had actually increased, and her pulse was slippery, wiry, and fine. This condition was interpreted as a depression of wood over-controlling earth  producing an accumulation of dampness which in turn generated phlegm. The plan was to treat the liver and spleen together with the administration of Settling the Liver Extinguishing Wind Decoction (Zhen Gan Xi Feng Tang) to balance the liver and extinguish wind in combination with Pinellia Atractylodes and Gastrodia Decoction (Ban Xia Bai Zhu Tian Ma Tang) to fortify the spleen and transform phlegm.

The patient was examined for a third time on March 13.

After taking two of the above formula the patient’s dizziness remained as before, the headache had spread, occurring suddenly, sometimes anteriorly, and sometimes posteriorly, sometimes on the left, and sometimes on the right. Her hands were numb, and she had a tremor in her extremities. She had a dry bitter taste in her mouth, and had little control over her lingual movements. Her tongue coat was thick, and her pulse was fine and wiry. Two prescriptions had been administered over the course of a week and there had been no improvement. I grasped hold of the idea that “In treating wind first treat the blood, and in circulating the blood, the wind will be extinguished of its own accord.” Therefore the patient was given Persica and Carthamis Four Ingredient Decoction (Tao Hong Si Wu Tang). This contained:

Semen Pruni Persicae (Tao Ren) 15g.
Flos Carthami Tinctorii (Hong Hua) 15g.
Radix Paeoniae Lactiflorae and Rubrae (Chi Bai Shao) 15g.
Radix Angelica Sinensis (Dang Gui) 20g.
Radix Coquitus Rehmanniae Glutinosae(Shou Di) 30g.
Radix Salvia Miltiorrhizae (Dang Shen) 30g.
Rhizoma et Radix Notopterygii (Qiang Huo) 10g.
Radix Ledebouriellae Sesloidis (Fang Feng) 10g.
Radix Ligustici Wallichi (Chuan Xiong) 10g.
Buthus Martensi (Quan Chong) 10g.
3 Formulae

The patient was examined for a fourth time on March 17th.

The headache had disappeared, lingual mobility had normalized, strength in her extremities had increased, the patient’s spirits had improved and she had already returned to attending to household duties. Her appetite was still lacking and she still occasionally experienced cephalic distension and tinnitus. She had a thin white tongue coat, and her pulse was deep and fine. Rather than change the prescription, additions of 10 grams each of Massa Fermentatae (Shen Qu), Rhizoma Atractylodis Macrocephelae (Bai Zhu), and Endothelium Corium Gigeriae Galli (Ji Nei Jin ) were made and 3 more formulae were administered.

Discussion:
The classic states “All wind  dizziness pertains to the liver.” In clinical practice whenever one treats dizziness one will typically endeavor to treat the liver using Gastrodia and Uncaria Decoction (Tian Ma Gou Teng Tang) or Settling the Liver Extinguishing Wind Decoction (Zhen Gan Xi Feng Tang) and this most often works well. In this case of dizziness, however, I first treated the liver alone, clearing and balancing the liver, but this approach proved itself to be rather confused and limited. On the next visit I perceived a disharmony of the liver and spleen and so used measures for strengthening the spleen and transforming phlegm in accordance with the principle that “if there is no phlegm there can be no dizziness. However, I failed to recognize that the patient was elderly and therefore depleted of qi and blood. Her channels had lost their nourishment, long term hypertension had impaired the resilience in her blood vessels, and blood flow was obstructed. The cerebral blood vessels were no longer nourishing her brain and this produced dizziness. The first mistake I made was in failing to recognize that the disease was one of the blood vessels, and in treating the liver and spleen therapy focused only on the viscera and bowels. My  second error was that in treating wind and phlegm I was only treating the qi, and so I had failed to treat the blood. In the end nourishing and quickening the blood, expelling wind and unblocking the connecting vessels produced a cure. Following this episode the patient had a number of relapses and Persicae and Carthamis Four Ingredient Decoction (Tao Hong Si Wu Tang) with modifications was always effective.

Treatment of Abdominal Distension Through the Spleen is Ineffective, but Diffusing the Lungs Yields Instant Results.
Zhang, a 17 year old male was first examined on June 16th 1991. Four years previously he had developed abdominal distension that had been left untreated. In recent years the abdominal pain had gradually increased in severity and was accompanied by cephalic dizziness, lack of strength, and dream disturbed sleep. Repeated Western and Chinese therapies had proven ineffective. Examination revealed abdominal distension upon palpation that intensified following meals, belching, dream disturbed sleep, fatigue and weak limbs, a white facial complexion, dry stools that he moved once daily but with difficulty, and a sense of prolapse following bowel movements. Gastroscopy revealed chronic gastritis. Barium meal examination revealed a 7 cm. gastroptosis. The abdominal area was soft, and felt better with  pressure. 

The tip of his tongue was red, and the tongue had a white coat, the root of which was slimy. His pulse was deep, wiry, and lacked strength.

[This was diagnosed as a case of] the spleen losing its healthy transportive function, stasis of the qi mechanism and lost of harmonious down bearing within the stomach. The treatment plan was to augment the qi and fortify the spleen, circulate the spleen and harmonize the stomach:

Radix Astragalus Membranosae (Sheng Huang Qi) 15g.
Radix Pseudostellaria Heterophyllae (Tai Zi Shen) 13g.
Rhizoma Atractylodes Macrocephelae (Bai Zhu) 9g.
Rhizoma Coptidis (Huang Lian) 9g.
Fructus Evodia Rutaecarpae (Wu Zhu Yu) 9g.
Pericarpium Citri Reticulatae (Chen Pi) 9g.
Rhizoma Pinellia Ternatae ( Ban Xia) 9g.
Fructus Seu Semen Amomi  (Sha Ren) 10g.
Endothelium Corneum Gigieri Gall (Ji Nei Jin) 10g.
Massa Fermentata (Shen Qu) 10g.
Rhizoma Zingeberis Officianalis Recens (Sheng Jiang) 3 pieces
Radix Glycyrrhizae Uralensis Preparatus (Zhi Gan Cao) 6g.

The patient was given 30 ji and the fatigue and lack of strength improved somewhat, however, the abdominal distension persisted. Careful inquiry into the illness revealed that the onset of the abdominal distension occurred following a bout the of the flu (gan mao). The patient had seen three physicians, all of whom had used methods for supplementing the middle and augmenting the qi to no avail, or had actually caused an aggravation of the condition. The patient’s condition was actually a case of damage to the lung. The illness was in the spleen but it originated in the lung. Therefore the plan was to augment the qi and diffuse the lung, warm the transportive function and fortify the spleen.

Radix Astragali Membranosae Recens ( Sheng Huang Qi) 30g.
Radix Pseudostellariae Heterophyllae (Tai Zi Shen) 13g.
Semen Dolichos Labab (Tu Bian Dou) 13g.
Pericarpium Citri Reticulatae (Chen Pi) 13g.
Fructus Seu Semen Amomi (Sha Ren) 10g.
Rhizoma Pinellia Ternatae (Ban Xia) 9g.
Cortex Magnolia Officianalis (Hou Po) 9g.
Semen Arecae Catechu (Bing Lan ) 9g.
Semen Pruni Armeniacae (Xing Ren) 9g.
Radix Platycodi Grandiflori (Jie Geng) 9g.
Herba Ephedrae (Ma Huang) 9g.
Radix Glycyrrhizae Uralensis Preparatus ( Zhi Gan Cao) 6g.
Rhizoma Zingeberis Officianalis (Gan Jiang) 6g.
Rhizoma Zingeberis Recens (Sheng Jiang) 3g.
Fructus Ziziphi Jujube (Da Zao) 3g.

Following administration of 3 of the above formula the patient became aware of a scurrying movement in his abdomen, a filtering sound in his intestine, frequent flatulence, and a sudden sense of lightening and relaxing in his intestines.

His tongue was red, with a white coat. His lung (pulse) was deep and wiry as above, but with strength.

The above prescription had addressed the illness and another 5 ji were administered unchanged. The abdominal distension vanished completely, and all the other symptoms disappeared as well. Gastro-barium examination revealed that the gastritis was cured, and the gastroptosis had reduced to 3 cm. To consolidate the therapeutic effect the above decoction was administered in pill form for long term recouperation. Six months later the patient reported the was still completely healthy.

Discussion
It is a general principle of abdominal distension that one must treat the spleen, however, in this case the normal therapies were ineffective. Mister Qiao’s meticulous examination revealed a number of things. The patient was able to eat, so the illness was not in the stomach; the flesh was not withered so the illness was not in the spleen. Based on the principles that “the lungs are the root of the qi”, and “the lungs rule regulation and have a reciprocal interior exterior relationship with the large intestine”, the illness was diagnosed as pertaining to a vacuity of spleen and lung qi. This resulted in symptoms of shortness of breath, and a lusterless facial complexion. The lung had lost its diffusion and depurative functions, the qi dynamic was not smooth, and there was an accumulation in the qi of the large intestine. All this resulted in distension in the abdominal region with palpation, and irregular bowel movements. Since there was a vacuity within the lung, the liver was not restrained and the Hun and the Po were not stored. This resulted in dream disturbed sleep. Once the cause of the illness was made clear the focus shifted to treatment of the lung. Heavy doses of Radix Astragali Membranosae (Sheng Huang Qi) and Radix Glycyrrhizae Uralensis Preparatae (Zhi Gan Cao) supplemented and augmented the lung qi. This was assisted by Herba Ephedrae (Ma Huang ), Radix Platycodi Grandiflori (Jie Geng), and Semen Pruni Armeniacae (Jie Geng) to diffuse and downbear the lung qi. Semen Arecae Catechu (Bing Lan) was combined with this to unblock and disinhibit the large intestine. Based on the principle that “in the case of vacuity, supplement the mother”, Radix Pseudostellaria Heterophyllae (Tai Zi Shen), Semen Dolichos Labab (Tu Bian Dou), Fructus Seu Semen Amomi ( Sha Ren), Pericarpium Citri Reticulatae (Chen Pi), and Rhizoma Pinellia Ternatae (Ban Xia) were used to fortify the spleen and the stomach to help with the generation and transformation of the source. The Rhizoma Zingiberis Officianalis (Gan Jiang) warmed the middle to disperse cold. In this way the lung qi descended, the spleen qi was raised, the pivotal dynamic was unblocked and disinhibited and the abdominal distension was eliminated.

External Cold Binds the Exterior
Wang, a 47 year old female, was first examined in February of 1985. She complained of fever, aversion to cold, and lack of perspiration over the previous two days. She was running a temperature of 38.8c, exhibited facial redness and suffered from cardiac vexation, a sore throat which made her hoarse, and a slight cough with thin white phlegm. Chest examination suggested a bronchial infection. Her pulse was floating and rapid, while her tongue was pale with a thin coat.  The patient was initially diagnosed with an exterior heat pattern and was administered Lonicera and Forsythia Powder (Yin Qiao San) which proved ineffective. The therapy was subsequently changed to Ephedra Decoction (Ma Huang Tang) with modifications

Herba Ephedrae (Ma Huang)
Ramulus Cinnamomi Cassiae (Gui Zhi)
Semen Pruni Armeniacae (Xing Ren)
Radix Platycodi Grandiflori (Jie Geng)
Flos Schizonepetae Tenufoliae (Jing Jie Sui),  10 grams each
Radix Glycyrrhizae Uralensis Preparatus (Zhi Gan Cao),  6 grams

One ji of this prescription was administered. This produced a sweat, the fever abated and all of the symptoms were relieved.

Discussion:
Item 32 of the Treatise on Damage by Cold (Shang Han Lun) states: “If a pulse is floating and rapid, the floating quality indicates wind, and the rapid quality indicates vacuity. The wind produces heat, while the vacuity produces cold and thus the wind and vacuity contend with one another resulting in aversion to cold as after a soaking.” A floating rapid pulse may be interpreted as an exterior pattern. The association of a rapid pulse with vacuity in this case suggests a vacuity of the yang. The idea here is that an exterior cold may bind the exterior, obstructing the interstices and depressing the yang. This causes a stirring within the vessels which produces a floating rapid pulse which is not contrary to the theory that “a rapid (pulse) means heat.”  Item 52 On Tai Yang Illness in the Treatise on Damage by Cold defines the therapy for this condition: If a pulse is floating and rapid one should induce diaphoresis and Ephedrae Decoction (Ma Huang Tang) is indicated. 

Yang Vacuity and Interior Cold

A 46 year old male was first examined in August of 1989.  He had suffered from functional cardio-neurosis (xin shen jing guan neng zheng bing) for more than 10 years. In the past six months he had noticed dizziness, mallar flush,  shortness of breath, lack of strength and appetite, and lack of warmth in the four extremities. His pulse was fine, rapid and lacked strength, while his tongue was pale with a thin coat. Cardiogram and encephalogram were unremarkable. The diagnosis tachycardia. He was given Brain Pleasing Extract (Nao Le Jing), and Restore the Spleen Pills (Gui Pi Wan) [implying a diagnosis of spleen qi heart blood vacuity]  but the condition did not improve. It was then decided that the condition was one of yang vacuity and interior cold resulting in the internal generation of vacuity heat. The strategy was then to administer Cinnamon minus Peony and plus Dragon Bone and Concha Ostrea Decoction (Gui Zhi Qu Shao Yao Jia Lung Gu Mu Li Tang) with modifications.

Ramulus Cinnamomi Cassiae (Gui Zhi)
Radix Codonopsis Pilosulae (Dang Shen)
Radix Morindae Officianalis (Ba Ji Tian)
Radix Glycyrrhizae Uralensis Preparatus (Zhi Gan Cao)
Rhizoma Zingeberis Exicatus (Gan Jiang ) 10 grams each
Os Draconis ( Long Gu)
Concha Ostrea (Mu Li) 20 grams each
Sclerotium Poria Cocos Spiritus (Fu Shen) 15 grams

With administration of this prescription for one month all of his symptoms disappeared.

Discussion.
Item 285 on Shao Yin Disease in the Treatise on Damage by Cold states: In shao yin disease the pulse is fine, deep and rapid, thus the disease is in the interior and diaphoresis should not be induced.” Item 122 on Yang Ming Disease states: “When a patient’s pulse is rapid, this rapidity indicates heat and so it is appropriate to dissipate the grains and conduct food (downward)…..Rapidity means heat is lodged and cannot dissipate grains resulting in a vacuity chill within the stomach.” An explanation of the Subtleties of Pulse Studies (Mai Xue Chan Wei)  states: “[When a pulse is] rapid, small and lacks strength, and it is empty (kong) upon palpation this is indicative of vacuity cold.” A vacuity cold condition should not be treated with diaphoresis since this only damages the yang further. The vacuity cold of the spleen and stomach causes internal generation of vacuity heat.