This entry is a guest post from Australia’s Greg Bantick. It is a case study that reminds us how easy it is to dream into what we think our patients think and feel and how stepping back and getting a clear view their presentation can help to leverage their innate resources and healing process.
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72 year old, male patient. First visit, in November ’05.
Initial observations: About 5’ 11”, thin, wiry build. Alert, but with a hesitant gaze; collapsed, weary sitting posture; quietly spoken with an unanimated, tired voice; sluggish gestures; deeply troubled and really wanting relief.
Chief complaints his words: general debility, chronic constipation, sharp abdominal pain on and off since he was in his teens.
From questioning: sharp, stinging epigastric pain, with spasms and visibly quivering from Ren 12 up to ribs. Sharp radiating pain to the rib sides is strong enough to make him jump, with the right side being worse. The pain is aggravated by deep breathing, constipation, frustration and stress; eating tomatoes, salt, and especially oily, greasy foods. Contrarily he has a deep, gnawing, constant hunger. All of these were made much worse since the bitter breakup of a relationship last year. In the months after breakup he was hospitalized for two weeks with cholelithiasis and he is now waiting for a cholecystectomy. The pain is relieved by relaxation, and the hunger with dry, bland biscuits. He also complains of long-term chronic constipation years, and will often go without a bowel movement for 4 – 5 days. When he does go the stools are loose, greasy, smelly and dark.
Secondary complaints: Frequent, often daily, dull temporal headaches, Or less often they can be sharp, unilateral, mostly on the right side when right side rib pain worse. Left side around Sp 9 had a boil like lump, now several small lumps, pricking pain, feels “like a maggot running around in it”. Right side thigh, UB channel sciatica, when sitting on hard seats or when sitting a long time.
Other observations: Broken sleep due to acid reflux, sleep easily disturbed by noise and also because he has to urinate 2 -3 times a night. Very tense abdomen especially midline above navel. Many long surgical scars on the abdomen, including one from around Ren 9-14. Most of the abdomen is tender to light touch, making him wince when palpated.
History: As we spoke, he became more talkative and engaged with a remarkable ability to view his life objectively, and with a dry sense of humor. He has faced many difficult challenges in his life. In the interest of brevity, I will only mention a few that influenced my thinking. The abdominal scars were the result of several unnecessary surgeries up to age 19, performed at the insistence of his mother who suffered Munchausen by proxy syndrome. In his late twenties, he became a bank manager in a small town. He married, had 4 children, and lived happily in their small community. Much later, when his children were adults, he learnt from a friend that none of them were his. They were all fathered by his wife’s various lovers, and the reason she was late for their wedding was that she was having a “quickie” with the best man, then his best friend. Later, during his second marriage, in his sixties, he was kicked and beaten; including several kicks and blows to his abdomen. The beating was at the hands of his new wife’s son and daughter in law, following a dispute over her money. His wife was beaten too.
P: thin, deep, collapsing on pressure. ST and GB pulses had a rising up, floating sensation
T: thin, tending pale, moderately thick, dirty white coat
Diagnosis: focal distention in the epigastrium with counterflow of ST qi
My thinking: The patient had tried acupuncture with limited success. He was willing to give it another try, but had been referred to me primarily for herbs. I suggested we do both as I thought acupuncture, plum blossom hammer and moxa locally for the scarring would be useful. I was uncertain of my ability to help with his heavy burden, both psychological and physical. I thought that the pain in the abdomen, given its onset and duration, must be contributed to by the scar tissue, and was uncertain if herbs would help so long after the surgeries. I felt confused and saddened hearing his story, thus making it difficult to feel clear about my diagnosis. It felt easier to go with Liver qi constraint invading the Stomach based on the pain radiating into the hypochondria, long term frustration and anger (although in conversation he did not seem bitter, I just couldn’t imagine he wasn’t), aggravation by oily, greasy foods and temporal headaches all seemed to fit that diagnosis. Other factors made me go in a different direction. In thinking of his history and the impact on his health, I was drawn to a wider view of treating the qi mechanism.
Some key indicators to me;
-the main belly symptoms were on, or originated near the midline
-qi movement was unsmooth; there was pain in the epigastrium, tension in the abdomen depression and irritability, alternating constipation and loose stools
-qi was rising; reflux, headaches, poor sleep, sensitivity to noise, gnawing hunger, much rumination, constipation
-qi was sinking: frequent urination at night
Initially I was thinking I would need to use strong qi and blood moving herbs, especially in treating the scar tissue. I was also uncertain of his ability to digest and persevere with raw herbs. Given the duration, I was thinking this was going to be a long course of treatment. I was not confident that I had understood the case well and was tempted to write a long formula trying to address everything. In the end, I decided on a modification of Pinellia Decoction to Drain the Epigastrium (bàn xià xiè xïn täng) based on the midline focal distention and stomach symptoms and because I wanted to adjust the qi mechanism and harmonize counterflow. Aside from the other indicators for the formula I was thinking;
Pinelliae Rhizoma preparatum (zhì bàn xià) 9g and Zingiberis Rhizoma (gän jiäng) 6g; for their acrid flavors, which penetrate the qi and disperse. To dissipate epigastric focal distention and improve the ascending and descending of qi.
Scutellariae Radix (huáng qín) 6g, Coptidis Rhizoma (huáng lián) 3g; bitterness clears heat and drains downwards. Coptidis Rhizoma (huáng lián) clears heat in the heart, further encourages the descending action, clears heat and calms the spirit.
Ginseng Radix (rén shën) 6g, Glycyrrhizae Radix preparata (zhì gän câo) 6g, Jujubae Fructus (dà zâo) 6 pieces; Glycyrrhizae Radix (gän câo) is sweet and neutral. Jujubae Fructus (dà zâo) and Ginseng Radix (rén shën) are sweet and warm. One reason for epigastric focal distention is due to inhibition of the descending and ascending movements of qi. These sweet medicinals harmonize the center, freeing both above and below.
+ Salviae miltiorrhizae Radix (dän shën) 6g; one of my favorite herbs, it is bitter and slightly cold. It invigorates the blood, dispels stasis, clears heat, soothes irritability, as well as nourishes the blood and calms the spirit.
+ Aurantii Fructus immaturus (zhî shí) 6g; is bitter and acrid and slightly cold. It breaks up qi stasis in epigastrium and abdomen
Cooking instructions: cook each packet in 10 cups of water, cook down to 6 cups, remove ingredients and cook again until 4 cups remain. Take 1 cup in the morning and evening over the course of two days.
Second visit one week later. His pain was markedly reduced, and with a complete lack of sharp pain episodes. Reduced frequency and intensity of reflux, and bowel movements were regular for the first the days of taking the formula. No change to headaches or gnawing hunger. He looked more relaxed and energetic, but complained of being more irritable. He described some episodes where he had gotten angry. I considered this a step in the right direction as his qi was moving, he was not depressed, and could more easily acknowledge his anger.
P: thin, deep, stronger. No floating quality. Liver pulse weak on pressure. Continued acupuncture and the original formula.
Third visit one week later. Only one short, painful abdominal spasm that radiated toward the right side, otherwise no pain. No reflux and now sleeps through the night. Less gnawing hunger, able to eat a wider range of foods and enjoying eating. Frequency of headaches reduced, less irritability, more energy and he was clearly happier. Lumps at Sp 9 were minimal. Still tending toward constipation. P: less thin and tight, the liver pulse was stronger. Continued acupuncture and the formula adding Ophiopogonis Radix (mài mén döng) 6g, to moisten the intestines, clear heat and irritability, as well as supplement and preserve Stomach yin and Rhei Radix et Rhizoma (dà huáng) 3g, as its bitterness and cold clear heat and it also resolves blood stasis.
Fourth visit one week later. No epigastric or abdominal pain, no gnawing hunger, only one headache, much less irritable, more energy and a happier disposition. Missed a bowel movement one or two days, but didn’t feel uncomfortable not having gone. I continued to see the patient a few more times with continued improvement, until he moved interstate. During this time I also saw his second wife. They reconciled and were going to buy a place in the country and grow organic vegetables and herbs. Both were happier and healthier. As far as I know he has not needed the surgery.
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I see many patients with mood disorders, most of them with histories of real difficulties and trauma. While often being touched by their willingness to share so personally and deeply, I am sometimes thrown by the depth of their suffering. It can be hard to reduce their narrative to an easy syndrome differentiation. I sometimes doubt mine, and my medicines ability to heal and bring real change in these peoples lives. However, when I do my best to follow our elders and their understanding of qi medicine, and I borrow their ideas as encapsulated in their formulas, I am often really surprised at how effective our medicine can be. I also learn that adjusting the qi mechanism clearly resolves physical problems and also soothes deep emotional hurt as well. Many other SHL formulas share with Pinellia Decoction to Drain the Epigastrium (bàn xià xiè xïn täng) its simple, gentle and elegant construction, which focuses on adjusting and harmonizing the qi mechanism.
