by Bob Flaws

Just before lunch today, I was sitting in the customer service "bull-pen" listening to our CS people answer questions over the phone. One call, which lasted almost a half hour, was about treating a patient with primary biliary cirrhosis (PBC). Primary biliary cirrhosis is an autoimmune liver disease, and I don't remember ever seeing anything about this in the Chinese medical literature. After listening to the call, I went back to my office to read up on PBC and to think about this condition from a Chinese medical point of view. What I'd like to describe in this blog is how we problem-solve in Chinese medicine in a situation like this.

...

According to what I read on-line, the initial symptoms of PBC (and liver cirrhosis in general) are, fatigue, weakness, loss of appetite, nausea, possible weight loss, and itching. As the condition progresses, there can also be jaundice, edema, ascites, spider nevi, easy bruising, and nosebleeds. Each of these symptoms are either diseases in their own right in Chinese medicine or well-known, major symptoms. As practitioners of Chinese medicine, we are expected to know the disease mechanisms of fatigue, weakness, loss of appetite, nausea, weight loss, itching, jaundice, edema, ascites, easy brusing, and nosebleeds. Taken one-off, there is nothing advanced or esoteric about any of these. For instance, nosebleeds are typically either heat forcing the blood to move frenetically outside of its vessels or spleen qi failing to contain the blood within its vessels. Similarly, jaundice is either spleen dampness if the color is dull yellow or liver-gallbladder damp heat if the color is bright yellow. Thus we should be able to go through each of these symptoms and state the main disease mechanisms posited in Chinese medicine.

Taken as whole, fatigue, lack of strength, loss of appetite, nausea, and weight loss all point to spleen vacuity. Each and everyone of these may potentially be due to spleen vacuity. In addition, fatigue is a halleluja symptom of spleen qi vacuity. Therefore, it makes sense to hypothesize that there is spleen vacuity. Such a hypothesis is further strengthened by edema and easy bruising. Certainly, spleen qi vacuity is a major mechanism of water swelling, and easy bruising is yet another symptom of spleen qi failing to contain blood within its vessels. A quick look at the tongue and feel of the pulse should confirm this without much difficulty. If there is spleen vacuity and if there is jaundice, then it is likely that it is spleen damp jaundice. A quick look at the patient's face should confirm this as well.

That then leaves nosebleeds, spider nevi, ascites, and itching. As stated previously, nosebleeds are mostly due to spleen qi vacuity or lung-stomach heat. If there are lots of other symptoms of spleen vacuity, then that should be our working hypothesis until or unless we uncover signs and symptoms of heat. Spider nevi are a species of venous engorgement. They basically indicate blood stasis. Again, a quick look can ascertain if there are or are not spider nevi and, therefore, blood stasis. Ascites on the other hand corresponds to the Chinese medical disease category of drum distention. The patterns of drum distention listed in most basic internal medicine texts are qi stagnation and damp obstruction, cold dampness encumbering the spleen, damp heat brewing and binding, liver-spleen blood stasis, spleen-kidney yang vacuity, and liver-kidney yin vacuity. These are all well-known patterns, and practitioners should know how to quickly question and examine for these. If there is spleen damp jaundice, then we would not expect there to be damp heat drum distention. So once again, we should be able to prioritize among these potential disease mechanisms based on what we've already established, i.e., at the very least a spleen qi vacuity. As for itching, it can be due to wind, blood vacuity, or blood stasis. Since the spleen is the latter heaven root of the engenderment and transformation of blood and we already have confirmed there is spleen vacuity, my first hypothesis is that the itching is due to blood vacuity. Blood vacuity may then give rise to wind and/or blood stasis.

Of course, we are also going to take into account the patient's sex, age, and body-type or constitution. In the case of PBC (as in most other autoimmune diseases), most patients are female, and we know that women are prone to both blood vacuity and spleen vacuity. If the patient is in her 50s or 60s, we need to consider spleen-kidney yang vacuity and/or liver blood-kidney yin vacuity. Hence simply due to age, we might expect either a qi and yin dual vacuity or a yin and yang dual vacuity.

None of this is rocket science. It is simply thinking within our system. I can't recommend too highly the following basic step-by-step methodology:

1. Reframe the patient's Western disease into the corresponding traditional Chinese diseases by focusing on the major clinical symptoms.

2. Pattern discriminate each of those traditional Chinese diseases, taking into account the patient's sex, age, body-type, and any common disease mechanisms between these symptoms/Chinese diseases.

3. Question and examine to confirm or deny your working hypotheses.

4. When you feel you have identified the patterns present, state the treatment principles for those patterns in the same order.

Now, whether you're doing acupuncture or herbal medicine, you should know how to practically accomplish those treatment principles. So you design and implement a treatment plan and see what happens. Based on what happens, you refine your pattern discrimination, your treatment principles, and, therefore, your treatment plan, and you keep doing this over and over until the patient is cured, markedly improved, or at least stabilized.

There are no secrets to any of this. There is only knowing how to use this system in a systematic way.

BTW, I'm off for five days to meditate in Mt. Shasta. Be well.

Copyright Blue Poppy Press, 2009. All rights reserved.