The Nail Biter:
A Chinese Herbal Case Study
Plus Formula Discussion with Brian Carter
Financial Disclosure: Brian Carter is a co-owner of TCMFormulas.com,
the prescription service for acupuncturists and Chinese herbalists
Warning for Readers: This
article is dense with Chinese medicine concepts and abbreviations,
and is meant for trained herbalists. But feel free to
try to understand it - if you dare!
The Nail Biter
J has been a nail biter every since he can remember. Now 34 years
old, he has been a slave to this habit for three decades. Upon
inspection, his nails are chewed down half way to the root and
have prominent vertical ridges. His past medical history is "insignificant"
except for having his gall bladder removed at age 26 at the recommendation
of his doctor due to a blocked duct resulting in 2 severe gall
J has a high stress job in the financial industry which he believes
is taking a toll on his health. He suffers from fatigue and difficulty
sleeping in which he feels fidgety for most of the night. While
he is generally a mild mannered person, he admits to suppressing
difficult personal and emotional issues. He suffers from headaches
which are localized to the lateral aspect of the eye at the acupuncture
point Gall Bladder 1. Floaters are confirmed in his left eye.
He has constant nasal congestion with yellow discharge.
Tongue and Pulse
His tongue is deep red, thick, tender with severely deep cracks
throughout (horizontal and vertical). His tongue is slightly quivering
and dry with a slight patch of dry yellow fur on the left side
of the root. His pulse is irregular with variations in the rate,
markedly thin and forceless with wide changes in intensity on
the left side. The right side is tight and slippery with a reduced
J was diagnosed with extreme exhaustion of his heart and liver
yin and blood, complicated by kidney yin and yang deficiency,
and liver qi stagnation and spleen qi deficiency. His main symptom
of nail biting can be seen as a defense mechanism by which he
subconsciously attempts to stimulate the liver to produce more
blood and invigorate qi. By biting the nails, the outward manifestation
of the liver, the liver is called into action. Often times, a
deficiency in an organ will lead to an apparent excess in its
interiorly-exteriorly related pair. Here the gall bladder evidences
signs of excess (gall stones, headaches at GB 1). The lungs are
able to become excessive across the control cycle and chronic
nasal congestion results. This is contributed to by the spleen's
increased demand to produce blood and provide nourishment to this
chronically depleted individual. This increased workload further
damages the spleen and produces the dampness which gets stored
in the lungs as phlegm and nasal congestion. Because this process
is one which has spanned decades, the kidneys are implicated as
a possible root and are further depleted in the process.
Herbal Formula Treatment
With all of this in mind, the initial focus was to supplement
heart and liver yin and blood, as well as move liver qi and regulate
the spleen and stomach. The herbal treatment was TCM Formulas'
preparation (combination of liquid extracts) of Suan Zao Ren Tang/Gan
Mai Da Zao Tang combination (2/3) + (Chai Hu) Shu Gan Wan (1/3).
This is great! Thanks for doing that. It really gets my neurons
firing... The case is great- psychological and physical both...
I have a few comments/questions:
- Do you have a follow-up result on it? It would be nice to
have that rather than just ending on the prescribed formulas.
- Can you provide a rationale for not addressing the Sp qi xu
and K xu? Or explain how the formulas do?
I was wondering myself if you might have also done 1/3 of xiang
sha liu jun zi tang (for the Sp qi xu and damp)... just some peer-review
thoughts for you.
My thoughts for not directly addressing the Sp and Ki defic are:
- I believe that the Sp defic is a branch resulting from overtaxation
by needing to provide extra nourishment to the body from the
Lv/Ht/Ki defic. By correcting those deficiencies, my thought
is that the Sp issues will resolve.
- We are working with a limited amount of dosages, especially
when using only 5 droppers 2x/day. Adding another formula to
address the Sp and/or Ki issues, in my opinion, would have weakened
the initial focus of addressing the Ht and Lv yin and blood.
With Shu Gan Wan, my opinion is that while there is no strong
supplementation taking place, by moving the Lv and allowing
the St to do it's job without hinderance, that it is being indirectly
strengthened. Also, the bai shao is great for nourishing the
St yin which helps the Ki yin indirectly. The chen pi, qing
pi, sha ren, bai dou kou help to strengthen the St and regulate
it's qi. Once St qi is regulated and it's energetics are downward,
it is able to function optimally. Also, the chen xiang has an
affinity towards the Ki, being heavy, so it is able to bring
the other herbs in the liquid combo down to the Ki. Thus, some
of the supplementing and moving herbs make it to the Ki. This
is one of the reasons that I love Shu Gan Wan and why I include
it in so many of my prescriptions.
- I wanted to aggressively tackle the yin and blood defic and
provide some quick results. This is really a long-term game
plan in my mind. His deficiency is pretty severe. Once I have
him stabilized, I plan on incorporating Ki tonics to strengthen
his constitution and secure long-lasting results.
So far I have been treating him for a few weeks (usually 2x/week).
During that time he came down with a flu which changed our focus
for a couple treatments. Overall, he is improving. His nail biting
is markedly decreased. He has mild "binges" every few
days where he used to have prolonged binges daily. His energy
is still fairly low, but he feels more at ease. His pulse on the
left side is becoming palpable. On the first visit, I could only
feel a thin feeble pulse at the cun. Now all three positions are
felt, but are still thin and only in the blood depth.
I love hearing other practitioner's input. What do you think?
Not sure about point #1- Just haven't often thought about Sp
xu as a branch...
In general (not this case) I suppose I think of Liv, K, and Sp
as the most common roots- although could be H from emotional shock...
anyway, you know the case and history better than I, so some details
not written in the case study may have had an impact on your diagnosis.
Given his age, unless he had a childhood hx of K xu, I'd think
Liv and Sp would be primary, and your pulse sounds like Liv was-
so I understand your short-term treatment plan.
That's an ongoing question for me, a vague area without a map-
when do we address branch more, root more, or try to address everything
at once. Likewise, accurate prognosis seems to be a very difficult
area of medicine. I'd love to see some more clear systematization
of these two things.
I like your explanation of (chai hu) shu gan... I still need
to get to know that formula better!
Your case sounds good. I'd like to integrate your answers into
the article, if I may.
I'm thinking about Sp defic as a branch along the lines of the
husband-wife imbalance which shows up in J's pulse picture. When
the right pulse is significantly stronger than the left, the theory
is that due to such a deficiency in the organ system (Ht/Lv/Ki),
the digestive system needs to work overtime in order to supply
those organs and the rest of the body with nourishment, qi, blood,
etc. This taxes the digestive system over time and eventually
will lead to a deficient condition. This deficient condition,
however, is a result of working hard to compensate for the organ
system deficiency. Thus, it is not primary, but secondary. Focusing
on the digestive system would be a branch tx because it would
do nothing to correct the organ system weakness. Strengthening
the organ system will take the extra load off the digestive system
and it should naturally regain its balance.
Feel free to integrate my answers into the case study.
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