lurking heat case

[Guest guest]

Jason

 

thanks for the link to chip's article. I had begun to think about a

particularly difficult case I am treating as involving a lurking pathogen.

I am going to try and recreate it from memory here for comment. I may

not be accurate with all the details, so wait till Laurie Burto chimes in

as she is also working on the case.

 

the patient is a female, 30ish with a young baby, maybe 6 months. she

generally appears to be in robust health. However, she has a several year

hx of recurring rhinitis, which went away during pregnancy and returned

with a vengeance after she gave birth. In between attacks, she is

energetic, with a moderate pulse and fairly normal tongue, though perhaps

a little dark and the coat a bit scanty in hindsight. Strong appetite, no

digestive problems, but a long history of constipation in terms of stool

only every other day. Perhaps signs of some interior heat, a hallmark of

lurking pathogen, but no signs of qi xu, in other words. the rhinitis

never involved exterior symptoms of fever, chills sore throat, cough or

bodyaches.

 

the patient also had a long hx of eczema, which was finally successfully

treated 7 years ago by a chinese herbalist known for expertise in

dermatology. the treatment included the regular use of creamy ointments

with unknown ingredients. A number of chinese ointments contain cortisone,

so it is unclear whether the patient was cured of her rash (another

interior heat sign that could be lurking pathogen in the ying, where rash

is a symptom). Chip noted that the appearance of rash is an ambiguous

sign and would more likely construe the pathogen entering the ying or

blood that it would a venting to qi or wei. It is very rare for

exteriorization to include a rash in wen bing case hx.

 

It would be a worthwhile tangent to consider how cortisone might have made

a pathogen lurk. Maybe cortisone clears the heat; this bring down the

rash, but fails to vent the pathogen fully, so it remains lodged at the

ying. Maybe cortisone even vents from blood to ying, but fails to go any

further. anyway...

 

Anyway, the patient is a student of mine and she at first wanted some help

in the formulas she was creating for herself. They were mostly focused on

tonification as she had reasoned that repeated acute attacks after

pregnancy and while breast feeding were due to some vacuity. Yet she did

not present as vacuous, at least at first. It now appears she does run on

empty, however this could also be due to heat in the ying causing her to

exhibit some fire flaring followed by crash and burn. Her strong appetite,

yet easy weight loss after delivery also may suggest some interior heat.

she is also often warm.

 

In a couple of weeks of this not working, I took over the case myself. I

deemphasized supplementation and focused more on dispersing, but mostly at

the wei level. the skin rash had been under control for many years at

this point. and I had every reason to believe it had been cured by

correct herbal treatment. Again, Chip is instructive when he suggests

that lurking pathogen complexes can linger and recur even after

" successful " tx. However I also included wu wei zi, because the patient

was having so much suffering from a runny nose despite repeated use of

variant of cang er zi san and er chen tang. Anyway this appeared to help

at first. The patient really cleared up quickly and the running stopped.

 

However even by the tail end of her own tonic formulas she had already

begun to complain of some redness, dryness and itching of her skin.

Thinking the formula was merely a bit too drying, it was slightly modified

to gently moisten and cool the blood some. It was at this point that the

patient got a full blown " wind invasion " . Apparently something passed

from her husband to her. this time she not only had true exterior

symptoms of fever and chills, but also severe inflamed eye with multiple

sties and discharge. Her skin is also quite flared up as well, worse than

in a long time. However her nose cleared up.

 

I have begun to think that perhaps the patient may have a lurking pathogen

that spontaneously vents to the protective level where it disrupts the

lung qi and provokes a rhinitis, yet is never fully expelled. If this is

the case, then clearing interior heat, which I have usually treated as

background noise in the acute condition of rhinitis, must be addressed

according to Liu. On page 231, Liu has an interesting skin formula in

this light, which vents pathogen from nutritive to wei, cools and moves

blood. It could easily be adjusted to open the nose.

 

first, is it reasonable that an exteriorizing pathogen would cause nasal

symptoms like this? I can't really find a precedent in my limited

resources.

 

second, I wonder whether the full blown windheat eye thing is an

exteriorization of the pathogen or a secondary initiator of the lurker.

 

basically,the zang fu approach has not yielded adequate results and the

patient is frustrated. I think this may be one of those cases where there

is not really a zang fu answer.

 

 

 

Chinese Herbs

 

 

" Great spirits have always found violent opposition from mediocre

minds " -- Albert Einstein

[Guest guest]

, wrote:

In between attacks, she is energetic, with a moderate pulse and

fairly normal tongue, . . . >>>

 

:

 

What is her pulse like during an attack? That should tell you what's

actually going on.

 

 

Jim Ramholz

[Guest guest]

Todd/Laurie,

Reminds me of what Craig Mitchell said about Xiao Chai Hu Tang presentations not just being about alternating heat and cold but about alternating symptom patterns in general. Remember the case of the woman who had alternating cough and no-cough?

Joseph Garner

 

>>> , <@i...>

wrote:

> I had begun to think about a

> particularly difficult case I am treating as involving a lurking

pathogen.

>    I am going to try and recreate it from memory here for comment. 

I may

> not be accurate with all the details, so wait till Laurie Burto

chimes in

> as she is also working on the case.

 

OK, I'm chiming in.... provided a good, detailed description of the major elements of

the case; I only have a few points to add.

 

She has been breastfeeding for 6-7 months.

 

Although the patient does give the appearance of being "robust" and

energetic, as Todd described, she has a tendency to totally crash

following bursts of energetic activity.  In fact, if there is any

constant or theme in this case it is the play of extremes....

Laurie<<<

[Guest guest]

, " James Ramholz " <jramholz>

wrote:

 

>

:

>

> What is her pulse like during an attack? That should tell you what's

> actually going on.

 

 

it is never floating, which is why I had rejected the recurrent exterior attack

hypothesis from the outset. but it still hard as Liu and chace say to determine

whether a pathogen is lurking internally or was generated there. is there

something about the pulse that would point to that.

 

[Guest guest]

, <@i...>

wrote:

> I had begun to think about a

> particularly difficult case I am treating as involving a lurking

pathogen.

> I am going to try and recreate it from memory here for comment.

I may

> not be accurate with all the details, so wait till Laurie Burto

chimes in

> as she is also working on the case.

 

OK, I'm chiming in.... provided a good, detailed description of the major elements of

the case; I only have a few points to add.

 

She has been breastfeeding for 6-7 months.

 

Although the patient does give the appearance of being " robust " and

energetic, as Todd described, she has a tendency to totally crash

following bursts of energetic activity. In fact, if there is any

constant or theme in this case it is the play of extremes.

 

For example:

 

[X] She had a history of extreme eczema which was

dramatically " cured " by unknown ointments.

 

[X] She had long history of susceptibility to " catching colds " which

dramatically abated during pregnancy, then resurged after giving

birth. Her " colds " are commonly accompanied by eye infections (sty).

 

[X] She reports a " ravenous appetite, " but she eats irregularly -

typically goes for 6 or more hours without eating and then feels

ravenous and eats a large meal to compensate. Despite these large

meals, she has had dramatic weight loss since giving

birth/breastfeeding.

 

[X] She is hyper-energetic followed by total wash-out periods - a

whole day during which she is virtually bedridden from exhaustion.

 

[X] She is gregarious, cheerful, almost excessively talkative during

her intakes, followed by weepiness and sleepiness during her

acupuncture treatments.

 

[X] She had nearly complete relief of her rhinitis symptoms while

taking protease (not w/ meals) for one month, but discontinued the

enzymes for no discernable reason.

 

Sorry - this is all I have time to add right now - haven't had a

chance yet to peruse the replies. I know there's great insight

lurking in this forum....

 

--Laurie Burton

 

 

----------------------

> the patient is a female, 30ish with a young baby, maybe 6 months.

she

> generally appears to be in robust health. However, she has a

several year

> hx of recurring rhinitis, which went away during pregnancy and

returned

> with a vengeance after she gave birth. In between attacks, she is

> energetic, with a moderate pulse and fairly normal tongue, though

perhaps

> a little dark and the coat a bit scanty in hindsight. Strong

appetite, no

> digestive problems, but a long history of constipation in terms of

stool

> only every other day. Perhaps signs of some interior heat, a

hallmark of

> lurking pathogen, but no signs of qi xu, in other words. the

rhinitis

> never involved exterior symptoms of fever, chills sore throat,

cough or

> bodyaches.

>

> the patient also had a long hx of eczema, which was finally

successfully

> treated 7 years ago by a chinese herbalist known for expertise in

> dermatology. the treatment included the regular use of creamy

ointments

> with unknown ingredients. A number of chinese ointments contain

cortisone,

> so it is unclear whether the patient was cured of her rash

(another

> interior heat sign that could be lurking pathogen in the ying,

where rash

> is a symptom). Chip noted that the appearance of rash is an

ambiguous

> sign and would more likely construe the pathogen entering the ying

or

> blood that it would a venting to qi or wei. It is very rare for

> exteriorization to include a rash in wen bing case hx.

>

> It would be a worthwhile tangent to consider how cortisone might

have made

> a pathogen lurk. Maybe cortisone clears the heat; this bring down

the

> rash, but fails to vent the pathogen fully, so it remains lodged at

the

> ying. Maybe cortisone even vents from blood to ying, but fails to

go any

> further. anyway...

>

> Anyway, the patient is a student of mine and she at first wanted

some help

> in the formulas she was creating for herself. They were mostly

focused on

> tonification as she had reasoned that repeated acute attacks after

> pregnancy and while breast feeding were due to some vacuity. Yet

she did

> not present as vacuous, at least at first. It now appears she does

run on

> empty, however this could also be due to heat in the ying causing

her to

> exhibit some fire flaring followed by crash and burn. Her strong

appetite,

> yet easy weight loss after delivery also may suggest some

interior heat.

> she is also often warm.

>

> In a couple of weeks of this not working, I took over the case

myself. I

> deemphasized supplementation and focused more on dispersing, but

mostly at

> the wei level. the skin rash had been under control for many years

at

> this point. and I had every reason to believe it had been cured by

> correct herbal treatment. Again, Chip is instructive when he

suggests

> that lurking pathogen complexes can linger and recur even after

> " successful " tx. However I also included wu wei zi, because the

patient

> was having so much suffering from a runny nose despite repeated use

of

> variant of cang er zi san and er chen tang. Anyway this appeared

to help

> at first. The patient really cleared up quickly and the running

stopped.

>

> However even by the tail end of her own tonic formulas she had

already

> begun to complain of some redness, dryness and itching of her

skin.

> Thinking the formula was merely a bit too drying, it was slightly

modified

> to gently moisten and cool the blood some. It was at this point

that the

> patient got a full blown " wind invasion " . Apparently something

passed

> from her husband to her. this time she not only had true exterior

> symptoms of fever and chills, but also severe inflamed eye with

multiple

> sties and discharge. Her skin is also quite flared up as well,

worse than

> in a long time. However her nose cleared up.

>

> I have begun to think that perhaps the patient may have a lurking

pathogen

> that spontaneously vents to the protective level where it disrupts

the

> lung qi and provokes a rhinitis, yet is never fully expelled. If

this is

> the case, then clearing interior heat, which I have usually treated

as

> background noise in the acute condition of rhinitis, must be

addressed

> according to Liu. On page 231, Liu has an interesting skin formula

in

> this light, which vents pathogen from nutritive to wei, cools and

moves

> blood. It could easily be adjusted to open the nose.

>

> first, is it reasonable that an exteriorizing pathogen would cause

nasal

> symptoms like this? I can't really find a precedent in my limited

> resources.

>

> second, I wonder whether the full blown windheat eye thing is an

> exteriorization of the pathogen or a secondary initiator of the

lurker.

>

> basically,the zang fu approach has not yielded adequate results and

the

> patient is frustrated. I think this may be one of those cases

where there

> is not really a zang fu answer.

>

>

>

[Guest guest]

, " " wrote:

> , " James Ramholz " > it is

never floating, which is why I had rejected the recurrent exterior

attack hypothesis from the outset. but it still hard as Liu and

chace say to determine whether a pathogen is lurking internally or

was generated there. is there something about the pulse that would

point to that. >>>

 

:

 

In these sort of skin cases there are two pulse senarios that are

most prevalent. The first involves damp heat of the liver sent out

to the qi or channel depth of the lung or large intestine. Usually a

blood building formula along with a patent to remove the damp heat

(I forget the name but it contains bear gallbladder, tortoise shell,

and snake) clears the condition.

 

The second senario involves blood and ying depletion, but showing a

strong contrast or disharmony between the qi depth of the large

intestine when compared to the qi depth of the lung (under normal

circumstances these two depths are balanced and communicate). So

both zang (lung) and fu (large intestine) metal positions are

lightly floating.

 

 

Jim Ramholz

[Guest guest]

CHA Mentors:

 

In a class last night we discussed a case study with an

interesting herbal strategy. The case is translated from a

Chinese source; I regret I don't have an exact reference.

It involved a 12-yr old boy recovering from nephritis.

While the first 3 wks of treatment predictably emphasized

damp-heat and blood stasis, the follow-up was a bit more

creative. Once the nephritis s/s were mostly resolved,

treatment began to focus on vacuity. The physician

prescribed two different formulas the patient took on

alternating days: one day he took formula A (kidney

emphasis), the next day he took formula B (spleen/stomach

emphasis), next day A, then B, and so forth.

 

While it's not unusual to see formulas which simultaneously

address different strategies (i.e., releasing the exterior

while strengthening spleen), it intrigued me to see the

strategies divided into separate formulas given every other

day. As is usually the case in published case studies, the

results were phenomenal - of course!

 

I was wondering if a strategy like this would be useful in

our lurking heat case in which extremes and fluctuations

seem to be the major nemesis in designing effective

formulas. It's naturally more labor-intensive, but this

patient is very likely to comply.

 

Any thoughts?

 

--Laurie Burton

[Guest guest]

In my observation, Li Dong Yuan was correct for chronic disease, you must

treat the stomach and spleen. Too often TCM trained physicians go for the

Yuan Qi or Kidney Qi/Jing, as if that were the root to everything.

 

 

 

Robert Chu, L.Ac., QME

chusauli

 

See my webpages at: http://www.wckf.net/chusauli/

 

 

 

 

 

>Laurie <tgperez

>

>CHA

> Re: lurking heat case

>Fri, 27 Jun 2003 07:38:59 -0700

>

 

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CHA Mentors:

 

In a class last night we discussed a case study with an

interesting herbal strategy. The case is translated from a

Chinese source; I regret I don't have an exact reference.

It involved a 12-yr old boy recovering from nephritis.

While the first 3 wks of treatment predictably emphasized

damp-heat and blood stasis, the follow-up was a bit more

creative. Once the nephritis s/s were mostly resolved,

treatment began to focus on vacuity. The physician

prescribed two different formulas the patient took on

alternating days: one day he took formula A (kidney

emphasis), the next day he took formula B (spleen/stomach

emphasis), next day A, then B, and so forth.

 

While it's not unusual to see formulas which simultaneously

address different strategies (i.e., releasing the exterior

while strengthening spleen), it intrigued me to see the

strategies divided into separate formulas given every other

day. As is usually the case in published case studies, the

results were phenomenal - of course!

 

I was wondering if a strategy like this would be useful in

our lurking heat case in which extremes and fluctuations

seem to be the major nemesis in designing effective

formulas. It's naturally more labor-intensive, but this

patient is very likely to comply.

 

Any thoughts?

 

--Laurie Burton

 

 

 

 

 

Chinese Herbal Medicine, a voluntary organization of licensed healthcare practitioners, matriculated students and postgraduate academics specializing in Chinese Herbal Medicine, provides a variety of professional services, including board approved online continuing education.

 

 

 

 

 

[Guest guest]

, " Robert Chu "

<chusauli@m...> wrote:

> In my observation, Li Dong Yuan was correct for chronic disease,

you must

> treat the stomach and spleen. Too often TCM trained physicians go

for the

> Yuan Qi or Kidney Qi/Jing, as if that were the root to everything.

 

 

I think this is one way...

 

-Jason