Experience with cases can teach the subtle art of classical Chinese medicine. Each individual has a story which presents a unique collection of challenges to his or her embodiment. Reviewing how treatments work, and sometimes even more importantly how they don't, brings new interpretations and insights.
Interesting and difficult cases become emblematic of concepts or aspects of theory they demonstrate.
Nearly eleven years ago, Ms. P sought help for debilitating fatigue with diffuse muscle pain and marked point tenderness at many locations on her extremities and back. While she reported sleeping a lot, careful questioning revealed she rarely slept more than a few hours at a time and didn't feel rested upon waking. Ms. P. was a 46-year-old woman with a 12-year-old daughter who had given up her job behind the counter of a café six months earlier. Her menses were long and pale. She appeared anxious, and reported feeling an occasional uneasy feeling in her chest. She feared she would never again have the energy to hold down a full-time job, and take care of her daughter.
Ms. P went to her medical doctor when she first became too tired to work. She was referred to two different medical specialists and eventually diagnosed with fibromyalgia. She failed to improve with the prescribed anti-depressant. During the months before trying acupuncture, Ms P consulted two other non-medical practitioners. She had taken vitamin supplements, two different herbal supplements, and most recently desiccated bovine adrenal glands. Each supplement had appeared to work for a few days then her symptoms returned with their previous intensity.
Ms. P's tongue was pale and swollen with a slightly red tip, which together with her symptoms, presented a confirmation remarkably close to the herbal formula "Restoring the Spleen Decoction" (Gui Pi Tang) used to treat deficiencies of Spleen Qi and Heart Blood. Even though Ms. P failed to improve with other formulas that appeared to address qi and blood deficiency with restless spirit, my conceit concerning the proven effectiveness of the Chinese formula suggested persisting with that diagnosis. After all, Gui Pi Tang was inspired by the Earth School and first published 750 years ago by Yan Yonghe in his text Formulas to Aid the Living (1253).
Points chosen by modern acupuncture criteria for this diagnosis might include: Ren 12, Stomach 36, Spleen 3 and/or 6, Pericardium 6, Heart 7 and an mian. Ms. P's presentation was close to the acupuncture confirmation for neurasthenia which suggests these points and others to support the Kidney. This syndrome is attributed to depletion of Kidney yin and yang failing to contain the Heart's physiological fire and support Spleen qi. This might be complicated by liver qi stagnation (disrupting the spleen) due to repressed emotions.
While I examined Ms. P, I also examined my investment in her apparent deficiency. Something wasn't quite right. Perhaps the Chinese formula is better designed than the eclectic ones she'd already taken, but if the basic idea was right, the other formulas should have worked a little. Both included ginseng, which tonifies source qi (Kidney), as well as spleen and lung qi. One could argue they should have helped some with that aspect of the acupuncture confirmation.
Ms. P's pulses provided some clue of a discrepancy; they were tight and fast indicating struggle, rather than small, soft or frail, which would have indicated deficiency. However, I suspected their interpretation was complicated by the inherent qualities being impacted by the previous failed therapies, especially the adrenal supplement. I was confused and allowed myself to stay in that uneasy place, rather than jumping to the secure diagnostic categorization suggested by these confirmations. I tried to look past her apparent deficiency to its source. That process might have been facilitated by someone else having tried the previous treatments. I realized the power of this and decided to practice regarding my own judgments from that distance.
The adrenal extract nourishes yuan-source qi, though it also can create an imbalance of its dissemination. In excess, even this vital physiological function becomes pathological. Perhaps treating the San Jiao mechanism to slow down the dissemination of yuan-source qi would clarify her clinical picture. In hindsight, this treatment strategy can be justified empirically simply as opposition to previous failed therapies and rationalized by the Chinese philosophical tenant: yang in excess (yuan-source qi) transforms into yin (fatigue). Part of the challenge in practicing Chinese medicine is to differentiate when to use "ordinary logic" and when to apply such philosophical principles.
The four main post-natal functions supported by jing-essence were each reflected in a point in the treatment strategy. Each was needled with mild dispersing technique angled downward. All except Ren 12 were needled unilaterally on the same side, chosen by point tenderness, especially at the top two points:
San Jiao 16: "Master point" of the Window-to-Heaven points, each of which is an important entry and exit point in the Neijing (Classic of Internal [Medicine]) tradition.1 Essential qi goes to each zang to convey emotions. It flows especially to the openings of the zang in their respective sense organs which receive the experiential input that triggers emotional reactions.
Stomach 12: The Empty Basin, an important entry point of the Neijing tradition, where qi goes from the external trajectories of the yang channels to the interior. Yuan-source qi eminates to the points named for it on the channels to support the functions of post-natal qi.
Lung 1: Front-mu point of the lungs. Yuan-source qi (in TCM language, Kidney yang) supports the lungs in grasping qi.
Ren 12: Front-mu point of the stomach, and influential point of the fu organs. To activate the polarization of the gu-valley qi, without which digestion does not function. In modern TCM terms, this polarization is expressed in the descending nature of the stomach qi, as it governs the alimentary canal and the ascension of the essence of the gu-valley through the transformation and transportation function of the spleen.
In addition to these points, Ki 16 was needled with balanced technique downward and deep on the same side as the others and upward and superficial on the opposite side. We all know the ascending flow of the Kidney channel as it presents in the continuous cycle of the primary channels (Lingshu, chaps. 10 and 16), but as an emanation from the zang to support post-natal energetics, it emerges from the interior at Kidney 16. From there it ascends to support digestion and breathing as they produce post-natal qi and descends to become sexual energy and fluids.
Finally, the liver source point was needled with balanced technique toward Kidney 1, also on the opposite side. The movement of yuan-source qi up and out through the dynamics of the liver channel was re-directed back down into the Kidney channel at its wood point. The Liver's responsibility for pushing jing-essence up to support post-natal energetics is signified by its having the lowest meeting points among all the primary channels with the Ren and Du vessels - at Ren 2 and Du 1. Thus, needling Liver 3 downward toward Kidney 1 can stimulate return of yuan-source qi to where it is stored, thus decreasing the rate it disseminates.
Eleven years ago, I didn't understand the relationship between the San Jiao mechanism and the divergent channels. While I'd learned information that Sanjiao 16 and Ren 12 were the upper and lower confluences of the SJ/PC divergent channel, I hadn't heard these symptoms were characteristic of that confluence. This wasn't even an accidental application of a fifth confluence treatment because I didn't apply the characteristic "needle three times" method. I simply treated the Sanjiao mechanism, inspired by Neijing channel theory and Nanjing point categories and hoped to clarify her clinical picture.
Ms. P. started sleeping well immediately after the first treatment, and quickly regained her energy. She returned to work at the café after three treatments within two weeks and required no further treatment. This amazing result could only have been inspired by an accurate treatment, upon which I'd had the good fortune to stumble. Yet, I remained plagued by the question: How does excess dissemination of yuan-source qi create fatigue?
Eventually, I developed a story that explained this symptom as a response, aimed at helping her retain jing-essence. According to this theory, Ms. P's embodied spirit was smarter than her personality and the therapeutic impulse to tonify her apparent deficiency. While her fatigue got in the way of what she thought she needed and wanted, it also forced her to rest (though ineffectively), which was what she really needed. This symptom expressed her life struggling to protect itself, rather than being a direct expression of pathology.
The one clear example of this thinking in modern TCM is the syndrome called "False Heat, True Cold," or what Shang Han Lun calls Shaoyin stage penetration of cold, where heat signs are understood as physiological rather than a direct result of pathology. There have been many other important response patterns recognized historically in Chinese medicine, and ideas concerning them have evolved. Early in Chinese medical history, heat wasn't even considered a pathogenic factor. Classical theory, exemplified by Neijing2 and Shang Han Lun (Treatise on Attack by Cold), considers heat a physiological response to pathogenic factors, rather than itself a pathology.
Much later, after the other three masters of the Jin-Yuan period (1115-1368) had focused on damp-heat pathologies, Zhu Danxi recognized the vital importance of differentiating between heat arising in response to dampness (as a pathology) and dampness responding to pathogenic heat. Members of the Imperial Academy's digestion specialty integrated this differentiation into their theory: the former clears through urine and the latter through the stools. Unfortunately, this type of differentiation has been eliminated from the modern clinical doctrine, which is based on classifying symptoms and signs into diagnostic categories of pathological manifestations, rather than differentiating between pathogenic factors and intrinsic responses.
Important as response patterns have been during the history of Chinese medical thinking, and while this story has served many patients over the years, it isn't necessary for explaining this case. Part of the function of the San Jiao mechanism is the conversion of jing-essence into post-natal humors. In this case, it's converted into much thinner and lighter jin-fluids to support wei qi. When overwhelmed, the San Jiao mechanism can't complete this conversion and the resulting fluids are too dense. This renders the wei qi sluggish, thus causing both soreness and fatigue.
Another way to look at this case focuses on poor sleep, which proved to be Ms. P's key pathological symptom. As soon as it improved, Ms. P's entire condition resolved. Although many TCM practitioners would attribute "waking without feeling rested" to Liver qi or blood stagnation, this symptom also can be attributed to blockage in the Pericardium, which prevents the shen-spirit from returning to rest in the chest. The San Jiao excess, as the yang organ/channel paired with the Pericardium, would then be attributed to the being's attempt to clear that block.
In any case, categorizing fatigue as a Spleen/Lung deficiency, possibly exacerbated by Kidney depletion, misses what proved to be the accurate diagnosis and treatment. Most symptoms can arise from several sources and various historical schools have explored many possibilities. Simply attributing symptoms to diagnostic categories based on a single tradition forsakes some of Chinese medicine's potential to stimulate healing.
(1) These points are mentioned directly after the command points (jing-well, ying-spring, shu-stream, jing-river, and he-sea) in chapter 2 of Lingshu. They are considered conduits between Heaven and Earth, between the experiential and the physical and instrumental in conducting the influence of the command points to the zangfu (organs). In addition to the entry and exit points among the external trajectories of consecutive channels, as described by Prof. Worseley's tradition, the Neijing tradition discusses them relative to movement between external and internal trajectories.
(2) Suwen, chaps 3 and 62 discuss the penetration of perverse wind. Beyond the most superficial layers (zhouli), the pathogenic factor is mixed with the individual's upright qi. Many symptoms arise from the struggle between them, rather than as a direct expression of pathology. For more on this, see "A Brief History of Wind" on www.daoistmedicine.com.
Click here for previous articles by Steven Alpern, LAc.
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