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The Amazing Dr. Zhang

Translated by Marcus Brinkman

An excerpt from "Dr. Zhang's Ingenious Use of Shang Han Lun Prescriptions" appearing originally in Oriental Medical Journal

Intern Zhang hurried over to the library. Just as she stepped through the doorway, she overheard Dr. Liu of the outpatient clinic cautioning old Dr. Zhong, "A patient with heart failure was given around-the-clock emergency treatment by our Western medical staff, without adequate results. They are now requesting the Chinese medical staff to diagnose and treat this patient under the guise of formality and in order to slightly reduce the burden of their responsibility. However, treatment of this kind of patient bears a big risk. If there is a change in her condition, who will be held accountable? You have a reputation that spans over thirty years, Dr. Zhong, so consider this appeal very carefully."

Intern Zhang thought to herself, "Heart failure is a precarious disorder, will Chinese medicine be able to cure it?"

"For the last thirty years, Chinese medicine has been held in lower regard than Western medicine. Accordingly, whenever confronted with a seriously ill patient we have customarily suggested they find worthier treatment than ours, not daring to bear the responsibility of our own care. Today, however, I believe Dr. Yang of the emergency room aspires to combine the use of Chinese and Western medicine, due to the accomplishments he has already achieved in the intensive care unit using the synthesis of the two.

Old Dr. Zhong established his position and then paused for a moment of composure before even more boldly continuing, "How can one catch tiger cubs without entering the tiger's lair ?! We should be willing to accept the burden of the risk in order to set upon a new path!"

Intern Zhang, moved by the manner in which old Dr. Zhong had spoken, paused momentarily before she opened the door of the doctors' quarters. In a respectful tone she said, "Dr. Zhong, the emergency room just phoned to request your attendance on an urgent case."

Intern Zhang followed old Dr. Zhong through the doorway of the second examination room, where a woman about sixty years of age was propped up on a bed, half lying, half sitting. Dr. Yang stood at the door way, nodding his head and motioning for Dr. Zhong to come in. Dr. Ying was examining the patient with his stethoscope, listening in complete concentration to the patient's lower lung fields. Then he turned around, placed a small stool at the side of the bed, and said cordially, "This is the patient we wish to diagnose in cooperation with the Chinese medical unit. Please have a seat and inspect her radial pulses."

Intern Zhang moved closer to the bed and carefully made her own observations. The patient's graying hair and wrinkled forehead indicated her advanced age. Her eyes lacked spirit, her eyelids were slightly puffy, her complexion was pale with flushed cheeks. Her lips had a light purple tinge and appeared dry. At closer inspection, her jugular vein could be seen pulsing. Her shoulders rhythmically lifted with each labored breath, and her back appeared hunched and shoulders slumped. This was the first time intern Zhang had encountered a patient like this. She had no idea if the patient was excess or deficient, cold or hot!

Dr. Zhong walked over to the side of the patient and sat down on the small stool. The patient's eyes opened slightly and a faint intent to smile appeared on her pale, uninspired face. Squandering her strength, she said, 'Ahh! It's Dr. Zhong! Do you still remember me? Thirty some years ago, when I was ill, you treated me! These past few years I haven't seen you around. This time my condition is hopeless." A paroxysm of deep, raspy coughs followed her words.

Dr. Zhong recognized the old women as a dear neighbor from long ago. He replied tenderly, "Mrs. Zao, don't worry. Now there is a combination of Western and Chinese medicine for your treatment, so the results will be even better than they were thirty years ago."

"Dr. Zhong, let me briefly present to you a summary of the patient's medical history." Dr. Yang stood next to the bed and continued, "Five days ago she developed cold symptoms and a cough. She became increasingly short of breath and by yesterday afternoon she was unable to breathe in a reclining position, so she came to the emergency room. She has a child hood history of rheumatic fever; over the last four years she has been admitted four times for congestive heart failure. She was successfully treated with digitalis and diuretics. This time she has been under observation and treatment in the emergency room for over twenty hours and we have been unable to stabilize her condition. Strophanthinum K was used three times, but it was not sufficient. In addition, she suffered from nausea and vomiting. In order to avoid digitalis poisoning of the middle warmer, it is necessary to gain immediate control of her heart weakness.

Therefore, we have asked you to consult on this difficult case. According to my experience, Chinese medicine in the treatment of heart failure is definitely effective. We would like you to manage this patient with us. Dr. Zhong listened to Dr. Yang as he continued palpating the patient's pulses. He first examined the right radial pulses in fine detail, then took her left pulses and inspected the old woman's tongue. Intern Zhang waited patiently for Dr. Zhong to finish and then began her own pulse and tongue examinations. She considered the pulses to be very unusual. None of the textbooks had described such pulses in detail. The pulse shape was winding like a snake, wiry and hard, and it appeared dispersed and arrhythmic, quickly changing from fast to slow and from big to small. The cubit position had no root, and upon pressure its strength diminished. The heart rate was approximately one hundred beats per minute. Both the left and right pulses were the same. The backs of the hands and wrists were noticeably cold. The tongue proper was light purple, and the moss was thin, white, and moist. Dr. Zhong then proceeded with a chest examination. One unit below the left nipple, a very distinct jumping movement could be seen, fast and irregular. He motioned to intern Zhang and in a whisper said, "This area is designated as empty interior (xu li). It is referred to in Neijing, Ping Ren Qi Xiang,(1) where it is written, "Movement of the clothing induced by a pulsing of the area below the nipple is indicative of zhong qi(2) vacuity, and, with the manifestation of extremely full and rapid respiration, is indicative of disharmony of the middle."

Even though intern Zhang nodded her head as Dr. Zhong spoke, she had not thoroughly studied the Nei-jing and therefore did not fully grasp the depth of Dr. Zhong's suggestion.

Dr. Zhong lightly palpated the patient's chest. There was slight evidence of pitting edema. In contrast, her abdominal region appeared slightly distended. He then reached under the blanket to touch her calf, from which he ascertained the lower extremities were also frigid. He then asked some questions about the patient's present circumstances. Before leaving the ward he picked up the cuspidor from a cabinet at the head of the bed, opened the lid and observed frothy white spittle that lacked any distinctive odor. Doctors Ying, Zhong, and Yang and intern Zhang returned to their department office where intern Zhang prepared to take notes. The four of them sat in contemplation for a moment before Dr. Zhong began to speak. "This is a water qi disease and there are three organs involved; the lung, spleen and kidney. However it is primarily due to a vacuity and weakness of the kidney's original yang qi. In addition, the yang qi has recently floated up and overflowed, manifesting as an inversion abandonment of blood and qi syndrome. Thus Shen Fu Tang with the addition of lung gu and mu Ii (dragon bone and oyster shell) should be administered. Also from Prescriptions of the Golden Chamber, it would be appropriate to use true warrior decoction (Zhen Wu Tang)(3) from the order of water regulating formulas. Are you all in agreement on this matter?"

"I agree with Dr. Zhong's proposal," Dr. Ying responded, "but I also think, as concerns diseases that are due to water retention, coursing the flow of yang chi and dispelling dampness through diuresis is very important; whether or not to add Five Poria Powders (wu ling san) is another concern."

"I believe Dr. Ying is correct." Dr. Yang had also studied Chinese medicine to a worthy degree. "Wu ling san's combination of cinnamon and poria not only courses the flow of yang qi, but also sinks the counterflow and calms the surging up. Recently this patient has also had another problem, a very obvious infectious lung disorder. Her white blood cell count is 29x10 (to the ninth power) with 93 percent neutrophils, and moist rales were heard over the lung bases. I've no idea how Chinese medicine views this kind of condition."

"According to Chinese medicine's differential diagnosis, it belongs to the category of phlegm heat in the lung," Dr. Zhong replied matter-of factly. "By observation of this patient's phlegm, it is apparent that she has some lung problems, but at the present this isn't our major concern. We should focus our attention on her weakness and deficiency of original yang chi."

"Would it be practical to add a large volume of heat-clearing and toxin resolving herbs to the ginseng, aconite, dragon bone, and oyster shell decoction?" intern Zhang interjected, expanding the parameters of the discussion.

"Warming the yang and tonifying the qi in conjunction with clearing the lungs and transforming phlegm is a new consideration. Theoretically it seems to be feasible but, practically speaking, can it be done?" Dr. Ying voiced his doubt at intern Zhang's proposal. She looked toward old Dr. Zhong for reassurance.

"Recently this patient's condition has manifested as yang vacuities of both the middle and lower warmers in combination with yin abundance. If cold chilling herbs are taken, they may cause the yin cold qi to revolt and vomiting may result. According to tradition, we usually await the yin syndrome's transformation to a yang syndrome, then, after the appearance of heat, a big dose of cold medicine is given." Old Dr. Zhong, drawing from his wealth of experience, did not favor the immediate use of cold-natured herbs. "Is there any other way to deal with both aspects of this problem?"

Dr. Yang raised his own point of view: "Use Chinese medicine to warm the yang, drain the dampness, tonify the qi, and reinforce the abandonment of qi and blood. For the treatment of infection use an intravenous infusion of streptomycin." All present assented to this method, so old Dr. Zhong dictated the following ingredients to intern Zhang.

  • Ren shen (radix ginseng) 3 qian
  • Fu zi (radix aconiti praeparata) 3 qian
  • Bai zhu (fried rhizoma atractylodis) 3 qian
  • Gui zhi (ramulus cinnamomi cassiae) 8 fen
  • Bai shao (fried radix paeoniae) 1 qian
  • Long gu (calcinated os draconis) 1 liang
  • Mu li (calcinated conchae ostreae) 1 liang
  • Ban ro'a (ginger fried rhiz. pinell. tern.) 4 qian
  • Ze zie (rhizoma alismatis plantago) 3 qian
  • Zhu ling (sclerotium polypori umbell.) 3 qian
  • Fu ling (sclerotium polypori cocus) 3 qian
  • Sheng Jiang (rhizoma zingerberis) 3 pieces
  • Two dosages

After a brief conference they decided to transfer the patient to the Chinese medical department, with Dr. Yang of the intensive care unit assisting in her observation. This arrangement would cause intern Zhang to be extremely busy. It was already after dinner and the patient's history and physical had not been completed, and Dr. Zhong's orders had not yet been charted. She also felt the need to analyze the signs and symptoms noted by Dr. Zhong and his diagnostic process. To further complicate matters, there were still some unresolved theoretical issues, the most striking of which was, as this was a case of heart failure, why had Dr. Zhong said it was a synthesis of lung, spleen and kidney ailments and hadn't mentioned the heart? The Chinese medical diagnosis was water qi disease, thus ginseng and aconite were used, as indicated for yin type edema. Furthermore, since there was phlegm heat in the lung, was it indicative of yang style edema? The areas around the patient's eye sockets were swollen, there was distention of the jugular vein, and her entire body was demonstrating symptoms of pitting edema, very similar to what is described in Synopsis of the Golden Chamber, as wind water edema due to affection by wind. However, Dr. Zhong considered this to be zheng style edema (characterized by whole body style edema). What was his reasoning? The patient's lips and tongue were light purple in color and her liver was enlarged so why weren't blood-vitalizing and stasis-transforming herbs being used?

Later that same evening, a faint gleam of light could be seen streaming through a crack in the door of the doctors' quarters. Apart from the lamp that lit the small cubicle intern Zhang occupied, no other signs of daytime bustle were evident. She concluded the last few entries into the patient's log with the hope that she would come to the understanding of patient Zao's case. She reviewed each point in detail, but was still confused on many important issues. It was then that Dr. Ying unexpectedly walked in. Intern Zhang was about to ask him for further help in clarifying those matters, when Dr. Ying spoke out. "Dr. Zhong has just come to see patient Zao. Even though her symptoms have not yet changed significantly, her condition has stabilized! After taking the herbal formula she sensed a feeling of warmth in her stomach and some slight improvement of her spirit ensued. Dr. Zhong has thus suggested that the patient's second dose of medicine be given in advance, and that the time between the first brewing and second brewing be shortened. This is in accordance with the Shan Han Luen's Cinnamon Decoction ingestion method:(4) "If the illness is serious, ingest the concoction twice, once during the day and once during the night then attentively observe. If after consuming the entire brew the pathogen is still present, then consume one more dose and shorten the time between the first and second brew."

"When the medicine is cooked, please go to the herbal decoction room and pick it up. And don't forget, tomorrow we are going to hold the case studies conference. You should also prepare."

That same night intern Zhang reviewed some traditional Chinese medical literature, and prepared a detailed examination report given by the emergency room staff.

  • Vitalsigns:
  • Body temp 37c
  • Pulse rate lOO/min
  • Respiration 24/min
  • Blood pressure 180/88

The point of maximum impulse was 3 cm lateral to the midclavicular line and its pulsation diffuse.

Heart rate 100-133/minute irregularly irregular.

The pulse had a deficient quality, and at the apex a grade III systolic blowing murmur was detected. Coarse bubbling rales and wheezes were heard over both lung fields, particularly the lower lobes. The liver was enlarged by two finger widths below the right costal margin but there was no evidence of splenomegaly. Lower extremities revealed bilateral pitting edema.

  • Blood routine:
  • Hemoglobin 9.1 gm/dl (deciliter)
  • Red blood cell 4.5 x 10 (12th power) liter
  • WBC 29.7 x 10 (12th power) liter
  • Neutrophils 93%
  • Lymphocytes 7%
  • Chest x-mys: Left ventricle and left atrium are enlarged, lung fields congested
  • EKG: atrial fibrillation, occasional ventricular premature beats, low voltage
  • Arm-tongue circulation time: 50 sec. (calcium glutinate)
  • Arm-lung circulation time: 11 sec. (ether)

On the second morning, as intern Zhang was walking into the patient's ward, she noticed that patient Zao was already able to recline comfortably, and the previous night had been able to eat a small portion of congee without nausea or vomiting. She then gave her an examination and discovered her heart rate had decreased from 133 to 88 per minute. In addition, her tongue had changed from purple to a slightly reddish color.

With resolute determination to clearly comprehend Chinese medicine and to demonstrate a proper sense of patronage, intern Zhang drew from old Dr. Zhong's experience and studied traditional Chinese medical theory, while simultaneously integrating those techniques with Western medical procedure.

Today, Dr. Zhong, Dr. Ying and Dr. Yang made their rounds of the patient's wards. Dr. Zhong proposed that even though the patient had made a change for the better, her fingers and toes were still cold, indicating that the yang qi was not yet full, so the treatment continued with the original formula, along with continued use of the cinnamon decoction ingestion method of multiple dosages per day.

After their rounds were made, they sat down together and began their case discussions. All of the interns were present and intern Zhang recorded the conference minutes. Dr. Yang was the first to speak. "Even though the effect of Strophanthinum-K appeared quite swiftly, purging the bowels quite rapidly, its benefit had already reached its peak. The patient's condition has since made a distinct improvement. This has mainly been the result of Chinese medicine. According to Dr. Ying's use of Chinese medical theory through pattern differential diagnosis: "Heart failure has two characteristic symptoms, edema and asthma," according to Zhang Jie-bin, author of The Theoretical Treatment of Edema. "Water accumulation below, and qi obstruction above create prolonged breath. This 'prolonged breath' and heart failure are very similar concepts, very specifically described, and worthy of our consideration. A discernment of heart failure edema may be recognized by differentiating the yin and yang components that are exhibited in each case. If the arriving force of the heart is slow then it is significant of yin. In addition, edema above is yang, as edema below is yin. Flesh that lifts up against the finger as pressure is released is of a qi correspondence and belongs to yang, while flesh that stays pitted as pressure is released corresponds to water and belongs to yin. As indicated by these yin/yang distinctions, this case of chronic heart failure edema is definitely a yin phenomenon."

"According to Prescriptions from the Golden Chamber, there are five categories of edema differentiation: wind edema appears to resemble zheng edema; however, within the category of wind edema, exterior symptoms are evident to a greater degree in contrast to the interior symptoms of zheng edema. Therefore, chronic heart failure edema still belongs to zheng edema, and in principle the kidney should be warmed.

"Heart failure asthma has three special characteristics: The first is that there may be no symptoms present unless the patient is subjected to physical exertion. Second, deficiency syndromes include symptoms such as a weak, low voice; shortness of breath; flustered behavior; panting; and a feeling of incompleteness on both inhalation and exhalation, in contrast to excess syndrome symptoms such as chest distention and coarseness of qi, high voice, and coarse open breath.

"Third, it may appear as though symptoms of coughing and phlegm are not serious. However, heart failure fundamentally belongs to deficiency syndrome asthma. Of key importance is that qi is not returning to the yuan, or in other words, kidneys are not grasping the qi. Phlegm is of secondary importance."

After Dr. Yang's discourse, Dr. Zhong made specific references to the following pathological observations: "This patient has been diagnosed by the Western medical unit as heart failure. However, from a Chinese medical point of view, this is a lung, spleen and kidney combination pathology. The lung has hot phlegm. The spleen has lost its normal adjustment, and the kidney yang is deficient and weak. The yang is not transforming the water, and the water fluids are overflowing and consequently assaulting the heart and squirting the lung, hence the qi is not returning to its origin and there is asthma as well as edema. Our modern Chinese medical books contain sections on heart yang deficiency symptoms that are essentially the same, and their treatment also includes kidney warming, aconite, and cinnamon prescriptions. Modern Chinese medicine and western medicine do not lie far apart in terms of their diagnostic categories. Shorten their conceptual distance and the relationships between them are easier to discern. This patient's condition has some kinship to the heart. Unclear mind, and the desire to sleep but inability to sleep peacefully, are manifestations of a confused mind."

Dr. Yang interrupted, "I understand Dr. Zhong's point. Spirit, thinking, all belong to the function of the heart. But, according to traditional Chinese medicine, the heart organ's pulsation ability, its propulsion and circulation of the blood and the fluids, are functions credited to the yuan qi, original qi, and correspondingly the yuan qi principally belongs to the kidney. I'm not sure if that is correct."

Old Dr. Zhong approvingly nodded his head and continued, "This patient also has manifestations of blood stagnation, however, recently this has not been the most important issue. Vitalizing blood and transforming blood stagnation belong to categories of attacking and resolving methods, so, if they were employed it would be difficult to avoid injuring the upright qi. Presently the most important task is to nourish the qi and warm the yang, for if the yang qi is full then there is force provided to circulate the blood. There is also one more point: This patient's cheeks are both very red, but rather than a yin deficiency, it is a full yang condition, or yang condition exceeding its limits, and is referred to as dai yang.(5) It is therefore necessary to use liberal amounts of os draconis and oyster shell to stabilize the desertion of yang qi from below."

"As concerns whether or not to treat this patient's exterior flu symptoms with exterior resolving herbs, because today the patient's tongue changed from purple to red, should her warming herbs be decreased?" Old Dr. Zhong paused for a moment. Intern Zhang quickly raised a question. "Start with the exterior and finish with the interior, is the conventional method of treatment. In this case, presently the interior is deficient and cold so we should immediately rescue the interior. According to the Shan Han Luen, Tai Yang section, if there is posterior body pain, and clear feces that can be self regulated, then immediately rescue the exterior."(6)

"Practically speaking, after the yang qi recovers, a slight amount of exterior evil may be resolved by itself, so there's no need to use exterior resolving herbs. In regard to the question of decreasing warming herbs . . ." Suddenly the phone rang, it was the hospital administration office reminding Dr. Zhong to attend a meeting that would soon be starting.

"Case studies will end here. If you have more questions please hold them for Dr. Zhong until tomorrow." As Dr. Ying concluded the meeting Dr. Zhong quietly excused himself.

Intern Zhang stood in the corridor, watching Dr. Zhong proceed down its long stretch before entering the conference hall. She was reminded of two lines from a poem: "With many responsibilities to bear on one's shoulders, the whipped horse cannot be dismounted to saddle."

As for Mrs. Zao's condition, after three days, she began to take one dose of medicinal herbs per day. One week later the redness of her cheeks was greatly reduced. The last formula eliminated dragon bone and oyster shell, and added licorice, dang gui, and semen cannabis. The amount of aconite was not reduced. After ten days her heart rate had stabilized at about 80 /minute, and rhythm had become more regular. The lungs' moist rales had disappeared. Hepatomegaly had resolved. Follow up blood work was within normal limits. She was released from the hospital after one more week's convalescence there.

Notes

  1. Ping Ren Qi Xiang (Treatise on the Healthy Man's State of Qi): This section deals with the pulse in various states of health.
  2. Zhong qi: This is the qi that serves as the dynamic force of respiration.
  3. Zhen wu tang (True Warrior Decoction):
    • Fu ling (poriae cocos) 3 liang
    • Bai zhu (rhizoma atractylodis) 3 liang
    • Bai shao (radix paeoniae) 3 liang
    • Fuzi (radix aconiti) 2 liang
    • Sheng jiang (rhizoma zingiberis) 3 liang
  4. The Cinnamon Decoction ingestion method, in simpler terms, is decreasing the time intervals between each dosage when there are exterior pathogenic factors that are not being resolved by following the normal standards of recommended dosages.
  5. Dai yang: Floating yang that is due to vacuity and cold of the lower warmer and thus symptomatically manifests as real cold and false heat.
  6. "If there is posterior body pain, and clear feces that can be self regulated, then immediately rescue the exterior." This passage relates to the misdiagnosis of an exterior pathogenic pattern; incorrect treatment with purging medicines will cause a condition of extreme depletion in which case acute diarrhea will result. It is then advisable to administer si ni tang in order to deal with the depletion condition and then quickly return to ridding the exterior pattern symptoms. This rationale is noted in the Shan Han Luen, Tai Yang chapter.

 


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