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 bladder attacks.

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 pounding quality.

Diagnosis

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).

Dr. Rosen,

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:

1. Do you have a follow-up result on it? It would be nice to have that rather than just ending on the prescribed formulas.
2. 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.

Thanks again!

B

Hi Brian.

My thoughts for not directly addressing the Sp and Ki defic are:

1. 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.
2. 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.
3. 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.

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?

Ross

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.

Thanks,
B

Brian,

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.

Ross

For more information:

• Ross Rosen, L.Ac. (New York/New Jersey)
• Brian Benjamin Carter
• TCM Formulas
• Find an acupuncturist/herbalist in your area