The excerpt below is from Volume II of Dr. Yu Guo-Jun’s excellent text entitled A Walk Along the River. (Thank you Eastland Press!) This volume will be released in early spring of 2019, just before Dr. Yu’s visit to the United States, Seattle, New York, and Amherst, MA. This case gives you an idea as to the depth of Dr. Yu’s thinking process when treating this patient’s chronic fever. As you will see when Dr. Yu teaches, he uses Cheng Yu frequently. Cheng Yu are short Chinese phrases similar to sayings like “it takes two to tango” or “six of one, half dozen of the other.” His texts are riddled with meaningful Cheng Yu. In this case, it is 茫無頭緒先“試探” “A confused state precedes a trial treatment.”
For many of us, being confused about a case can easily make us doubt our own abilities. Here, Dr. Yu uses the fact that the case is confusing both to diagnose and to set up his intentions as “trial.” Acting on diagnosis as hypotheses followed by an experiment allows Dr. Yu to learn from the case. Confusion, in this case, means two things: first, it means that it is likely that the issues fall into the Shao Yang conformation and secondly, that the case is not clear Yet.
In addition, this case gives a deep teaching about the nature of the Shao Yang presentation.
Six months of hot flushing, profuse sweating, and pain in the head and body
Patient: 58-year-old female
Half a year prior to our examination the patient had an injection of penicillin because of a urinary tract infection. three days later a host of symptoms arose as an atypical allergic reaction: headache, red face, throat obstruction, numb hands and feet, generalized aches and pains, hot flushing, and profuse sweating.
After using both Chinese and Western medicines the symptoms declined markedly. Only the headaches, body pains, hot flushing, and profuse sweating remained unchanged. Despite undergoing a host of Western medical tests, no infection or other problem was discovered.
The patient’s chart revealed that most of the herb formulas that she had taken had the functions of clearing heat, draining fire and enriching the yin, while simultaneously anchoring the yang. Intermixed among these were some formulas that aimed to expel wind and transform phlegm or dispel stasis and unblock the collaterals.
Intake Examination Date: February 1, 1993
Every day in the early morning about two hours before dawn she develops a severe headache, with a burning forehead, generalized flushing, aches, dripping sweat, vomiting, and a fever of 37.5-38.5°C [99.5 -103°F]. Despite taking pain pills when this occurs, she still moans and groans until dawn, by which time most of the symptoms have gradually resolved. Generalized aches, soreness and dizziness remain. During the day she is averse to cold and sweats when exposed to a draft . Her stools are slightly loose and, though her mouth is dry, she has no desire to drink. Her tongue body is red with a yellow, greasy coating and her pulse is sunken.
Differentiation of Patterns and Discussion of Treatment
PHYSICIAN A When treating illness, Chinese medicine strives to “seek for the cause by assessing the pattern and determine the treatment by assessing the cause.” In this case of six months of headache, body pain, hot flushing with profuse sweating, the clinical symptoms are complex and diverse, and the pulse and tongue seem to contradict the symptoms. Interior/exterior, heat/cold, excess/deficiency all are mixed up together and thus are hard to clearly differentiate. It is difficult even to grasp what exactly the chief complaint is and so there is no firm ground upon which to establish a treatment plan. therefore, all the treatments over this long period of time have been ineffective.
DR. YU Not only is the course of this disease prolonged, the subjective symptoms are also complex and diverse, and Western medicine is unable to find any kind of focus of infection. Further, the tongue body is red with a yellow, greasy coating; this yellow and greasy coating seems out of place in the overall presentation. Parenthetically, if you pay attention to the medical adage that “in seasonal [externally-contracted] diseases, emphasize the pulse; in miscellaneous internal diseases, emphasize the tongue” you will fall into an overly rigid way of thinking. In Chapter 5 of the Basic Questions (Sù wèn) it states, “ those who excel at diagnosis inspect the complexion and take the pulse, first distinguishing yin and yang.” In the end, is this a yin presentation or a yang presentation? I was at a loss and uncertain what to do.
After finishing the intake I sat and thought for a long time, as there is no way to prescribe a formula without grasping the main points of the problem. As you stated, interior/exterior, heat/cold, and excess/deficiency were all jumbled together and hard to clearly differentiate. I had no alternative but to use the “trial treatment” advocated by Zhang Zhong-Jing.1
Trial treatments require the use of formulas that serve as a trial test. This cannot be done without proper consideration. My experience has taught me that, for prolonged diseases that have not responded to numerous therapies, that have symptoms that are difficult to understand, and for which both the location and nature of the pathology are hard to determine, it is best to first try trial treatments using Bupleurum formulas, such as Bupleurum and Cinnamon Twig Decoction (chái hú guì zhī tāng).
PHYSICIAN B Why do you like trying Bupleurum and Cinnamon Twig Decoction (chái hú guì zhī tāng) in this case? Line 146 of the Discussion of Cold Damage (Shāng hán lùn) states, “Fever, slight chills, achy and uncomfortable joints of the limbs, slight retching, and propping knots below the heart [means] that the external pattern has not yet gone: Bupleurum and Cinnamon Twig Decoction (chái hú guì zhī tāng) governs it.” is comes about from lack of resolution of an exterior tài yáng pathogen which then spreads to the shào yáng and so this formula is used. It is half Cinnamon Twig Decoction (guì zhī tāng), which releases the not completely spent tài yáng pathogen, and half Minor Bupleurum Decoction (xiǎo chái hú tāng) to resolve the slight knotting of the shào yáng condition.
This patient’s condition has already lasted six months and so she not only lacks any incompletely released tài yáng pathogen, but also doesn’t have slight shào yáng knotting. Why would you dispatch this formula as the spearhead to treat this patient?
DR. YU Why would the relatively long duration of a disease preclude the existence of a Bupleurum (chái hú) presentation? As a younger person, Dr. Jiang once saw a woman who had been traumatized with fright from a fire after and repeatedly exposed to cold. This led to her having alternating chills and fever for more than half a year. As the course of the disease had been prolonged, her constitution weakened and she became very sensitive to sounds; all the doctors who saw her treated her for deficient presentations. Dr. Jiang cured her with one packet of the original formulation of Minor Bupleurum Decoction (xiǎo chái hú tāng).
As the current case does display a Bupleurum (chái hú) presentation, I would not dream of casually dispensing Bupleurum and Cinnamon Twig Decoction (chái hú guì zhī tāng) and hoping for the best. So, why would I want to use this formula here? You all know that the scope of the shào yáng is very wide. As the Qing physician Chen Xiu-Yuan stated, “Externally, the shào yáng controls the interstices and pores; internally, it controls the Triple Burner.” In this way, all the interstices and pores on the outside of a person’s body, as well as the thoracic and abdominal cavities on the inside of the body can be deemed as within the scope of shào yáng. Therefore, whenever I see a patient with a prolonged disorder that has failed multiple treatments, and where it is difficult to conclusively determine the site and nature of the disease due to a confusing set of signs and symptoms, I consider first using a Bupleurum (chái hú) prescription as a trial formula.
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1. Translators’ note: is refers to line 209 of the Discussion of Cold Damage (Shāng hán lùn) where Minor Order the Qi Decoction (xiǎo chéng qì tāng) is recommended as a test to see whether someone who has not had a bowel movement for six or seven days should be purged. A sense of shifting of the full feeling in the abdomen and the passage of gas are evidence of the presence of dried feces; real purgatives, such as Major Order the Qi Decoction (dà chéng qì tāng), are then recommended.